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UNIVERSITY OF MARYLAND 
- BALTIMORE 






JOURNAL OF THE MISSOURI STATE MEDICAL ASSOCIATION 


JANUARY. 1964 


Scientific Articles 


SYSTEMIC LUPUS ERYTHEMATOSUS ASSOCIATED WITH 
PROCAINAMIDE THERAPY, Andrew L. Hahn, M.D., 
Springfield 19 


BLOWOUT FRACTURES OF THE FLOOR OF THE ORBIT, 
Walter R. Stafford, M.D., and Stephen F. Bowen Jr., M.D., 

St. Louis 21 


VOLUME 61, NUMBER I 






USE OF NALIDIXIC ACID IN THE TREATMENT OF URI- 
NARY TRACT INFECTIONS, Herbert L. Warres, M.D., 
Springfield 27 


Special Article 

STATEMENT OF OPPOSITION OF THE MISSOURI STATE 
MEDICAL ASSOCIATION TO H.R. 3920 30 


OVARIAN METASTASES FROM CARCINOMA OF THE 
COLON, G. K. Kennard, M.D., R. A. Twyman, M.D., and 
and R. E. Allen, M.D., Kansas City 24 






Helps to make the epileptic's life more meaningful 





Effective in control of grand mal and psychomotor seizures, this agent enables the epileptic 



HVNI 


patient to lead a useful life. 

Indications: Grand mal epilepsy and certain other convulsive states. Precautions: Toxic effects 
are infrequent: allergic phenomena such as polyarthropathy, fever, skin eruptions, and acute 
generalized morbilliform eruptions with or without fever. Rarely, dermatitis goes on to exfolia- 
tion with hepatitis, and further dosage is contraindicated. Eruptions then usually subside. 
Though mild and rarely an indication for stopping dosage, gingival hypertrophy, hirsutism, and 
excessive motor activity are occasionally encountered, especially in children, adolescents, and 
young adults. During initial treatment, minor side effects may include gastric distress, nausea, 
weight loss, transient nervousness, sleeplessness, and a feeling of unsteadiness. All usually 
subsidewith continued use. Megaloblastic anemia has been 
reported. Nystagmus may develop. Nystagmus in combi- 
nation with diplopia and ataxia indicates dosage should be 
reduced. Periodic examination of the blood is advisable. •/. lj .- js . 


Contents for January, 1964 

Scientific Articles: 

Systemic Lupus Erythematosus Associated 
With Procainamide Therapy, Andrew L. 
Hahn, M.D., Springfield 19 

Blowout Fractures of the Floor of the Orbit, 
Walter R. Stafford, M.D., and Stephen F. 
Bowen, Jr., M.D., St. Louis 21 

Ovarian Metastases From Carcinoma of the 
Colon, G. K. Kennard, M.D., R. A. Twy- 
man, M.D., and R. E. Allen, M.D., Kansas 
City 24 

Use of Nalidixic Acid in the Treatment of 
Urinary Tract Infections, Herbert L. War- 
res, M.D., Springfield 27 

Special Article: 

Statement of Opposition of the Missouri State 
Medical Association to H.R. 3920 . . 30 


Departmental Features: 

Washington 6 

Across Missouri 8 

Missouri Academy of General Practice . . 10 

Woman’s Auxiliary 14 

President’s Message 34 

Editorial 35 

Ramblings of the Field Secretary ... 36 

News— Personal and Professional .... 38 

Deaths 38 

Missouri State Medical Association Prelim- 
inary Program 40 

The Missouri Society of Medical Technol- 
ogists 42"' 

County Society News 45 

From the Medical Schools 50 

New Members 61 

Missouri Medicine in Review .... 66 


Information for Contributors 


Articles are accepted for publication on condi- 
tion that they are contributed solely to this jour- 
nal. Material appearing in Missouri Medicine is 
protected by copyright. Permission will be granted 
on request for reproduction in reputable publica- 
tions provided proper credit is given and author 
gives permission. 

Manuscripts should be typewritten, double 
spaced, and the original with one carbon copy sub- 
mitted. Retain another carbon copy for proofread- 
ing. Used manuscripts are not returned. School and 
hospital appointments of the author should ac- 
company the manuscript. It is desirable that a 
synopsis-abstract of approximately 135 words ac- 
company the manuscript. Bibliography should be 
arranged at the end of the article in the order in 
which the references are cited in the text. The 
reference should give name of author, title of ar- 
ticle, name of periodical, volume number, initial 
page number and year. Authors are responsible 
for bibliographic accuracy. Bibliography should 
be double spaced. 

Illustrations should be glossy prints or draw- 
ings in India ink on white paper. They should 


not be mounted and name of author and figure 
number should be penciled lightly on the backs. 
Legends should appear on a separate sheet. 
Colored illustrations will be used when suitable 
if author assumes the actual cost. 

Legal difficulties may arise from unauthorized 
use of names, initials or photographs in which in- 
dividuals can be identified. Permission should be 
secured from patient or legal guardian and signed 
duplicate or photostat submitted with such photo- 
graphs or identification. The Editor and Editorial 
Board assume no responsibility for the opinions 
and claims expressed in articles contributed by 
authors. If citation of an institution related to the 
article is made, approval of the chief of service 
should be given in a letter accompanying the 
article. 

Reprint order blanks will accompany proof, 
which will be sent to authors prior to publication. 

All material other than scientific should be re- 
ceived prior to the first of the month preceding 
month of publication. 

Please give notice of change of address at least 
one month in advance of the change, giving old 
and new addresses. 


o 





King-Anderson Hearings — H.R. 3920 

Hearings started Monday, November 18, be- 
fore the House Ways and Means Committee on 
the King-Anderson bill and other legislative pro- 
posals involving medical-hospital care for the 
elderly. Originally scheduled to continue through 
Wednesday, November 27, the hearings were re- 
cessed due to the death of the late President 
Kennedy. Latest information indicates that Mr. 
Wilbur Mills, chairman, will reconvene the hear- 
ings sometime after January 1, 1964. 

Health, Education and Welfare. Secretary 
Anthony J. Celebrezze was the first witness when 
the hearings convened and the secretary reiter- 
ated many of the old arguments for a national 
medical care program for the aged financed 
through the Social Security system. Mr. Mills 
challenged the HEW cost figure and, during the 
intensive questioning of Robert Myers, HEW 
Chief Actuary, obtained the admission that the 
HEW’s proposed tax increase was about half 
as much as would be required to finance the 
program. 

Senator Karl Mundt (R. S. D.), charged HEW 
with the obstruction of the implementation by 
the states of the Kerr-Mills law. The Senator 
also charged specific members of HEW with 
traveling at taxpayer’s expense for the purpose 
of combating the success of Kerr-Mills. 

American Medical Association. AMA Presi- 
dent Edward R. Annis, M.D., and President- 
elect Norman A. Welch, M.D., presented the 
American Medical Association’s formal testi- 
mony in opposition to the bill. The AMA state- 
ment, containing a wealth of statistics and other 
factual data, related that the King-Anderson bill 
was a deceivingly expensive, inadequate and 
unnecessary proposal. The testimony told how 
the Kerr-Mills law was providing an increasing 
amount of care for the aged among those who 
could not otherwise provide such care and that 
voluntary efforts were providing an ever-increas- 
ing array of health care coverage. 

AMA testimony included the following ref- 
erences : 

St. Louis, Cleveland, Buffalo. Studies by the 


Conference of Catholic Charities in three lower- 
middle-income parishes in these cities showed 
that between 80 per cent and 90 per cent of the 
aged had hospital insurance, savings or potential 
help from children in case of illness. 

Church Projects. The Lutheran Church— Mis- 
souri Synod announced last June that 10 Luther- 
an projects for 748 living units for senior citizens 
had been constructed since 1961. In addition, 
federal mortgage insurance totalling more than 
$26 million had been approved or was in the 
process of being approved for 24 more housing 
projects identified as Lutheran which would pro- 
vide 2,299 units for the elderly. 

The Assemblies of God with headquarters in 
Springfield, Mo., cares for more than 2,400 per- 
sons in homes for the aged or nursing homes. 
Eighteen of these have been established since 
1960. 

MSMA Statement 

Representative Durward Hall (R. Mo.), a 
physician and a member of the AMA House of 
Delegates, testified against the King-Anderson 
proposal Wednesday, November 20. In his pres- 
entation, he included a summary of the written 
statement filed by the Missouri State Medical 
Association. Copy of MSMA Statement is pub- 
lished in this issue of Missouri Medicine on page 
30. Dr. Hall said that if federal programs such 
as housing, and aid to dependent children, did 
not require means test and everyone could use 
them regardless of income, “we would be practic- 
ing plain, unadulterated socialism.” 

Dr. Hall noted that he had asked a group of 
physicians in his district to assist him in the 
event he received any complaints from persons 
stating they were unable to receive medical 
care.” “I have not yet had to refer a single letter.” 

St. Louis County Medical Society Statement 

Written statement of the St. Louis County 
Medical Society was filed with the Ways and 
Means Committee in Washington, D. C., on No- 
vember 21, 1963, in opposition to the King-And- 
erson bill. The statement reported on the “Past 65 
Plan” sponsored by the society and put into 
effect in the latter part of 1960. “Physicians are 
taking steps to make certain that no one needing 
medical care goes without it because of inability' 
to pay. Through an organized voluntary plan, St. 
Louis County doctors are only doing what doc- 
tors have always done— but now they are doing 
it a little more systematically.” 


6 



Special cough formula for children 

Pediacof 


Each teaspoon (5 ml.) contains codeine phosphate 5 mg., 

Neo-Synephrine® hydrochloride (brand of phenylephrine hydrochloride) 2.5 mg., 
chlorpheniramine maleate 0.75 mg. and potassium iodide 75 mg. 

soothing decongestant and expectorant 



bright red, 
pleasant-tasting, 
raspberry-flavored syrup 

Pediacof is different. It is designed espe- 
cially for children, and each ingredient is in 
the right proportion. The potassium iodide 
in Pediacof is so well masked that it is virtu- 
ally unnoticeable. Children like the sweet 
raspberry flavor of bright red Pediacof. 

Dosage: Children from 6 months to 1 year, 
Va teaspoon; from 1 to 3 years, Vz to 1 tea- 
spoon; from 3 to 6 years, 1 to 2 teaspoons; 
and from 6 to 12 years, 2 teaspoons. These 
doses are to be given every four to six hours 
as needed. 


How supplied: Bottles of 16 fl. oz. 


Available on prescription only. 
Exempt Narcotic. 


Side effects: The only significant untoward 
effects that have occurred are mild anorexia 
and an occasional tendency to constipation. 
However, discontinuance of Pediacof has 
seldom been required. Mild drowsiness oc- 
curs in some patients but, when cough is 
relieved, the quieting effect of Pediacof is 
considered beneficial in many instances. 

Precautions and contraindications: Patients 
with tuberculosis or those who are known 
to be sensitive to iodides should not be given 
Pediacof. 

Caution should be exercised if Pediacof is 
administered to patients with cardiac dis- 
orders, hypertension or hyperthyroidism. 

Warning: May be habit forming. 

Winthrop Laboratories 
New York, N.Y. 


W/nfhrop 


1843M 


Ten-Year State Spending Trend — UP 



According to the Missouri Public Expenditure 
Survey, Jefferson City, a comparison of state ex- 
penditures in 1953 and 1963 show that appropri- 
ations have about doubled in the last ten years. 

Appropriations of General State Tax Receipts 
in the 1953-55 biennium are compared with the 
1963-65 biennium in the chart. 


$646,751,290 TOTAL 



PUBLIC 

SCHOOLS 


HIGHER 

EDUCATION 


WELFARE 


MENTAL 

HEALTH 


ALL 

OTHER 


PER CENT 
INCREASE 

+ 124 . 6 % 


+ 167.5 


+ 392.2 


+ 28.7 


+ 183.4 


+ 62.7 


1953-55 Biennium 


1963-65 Biennium 

8 




AH day long 

. . . keeps the patient calm, 
and the mind clear. 



All night too 

. . . aids restful sleep, with 
no barbiturate hangover. 


MEPRQ SPAN-400 

(MEPROBAMATE 400 MG. SUSTAINED RELEASE) 

Simplified, convenient dosage for emotional relief. 


Side effects: ‘Meprospan’ (meprobamate, sustained release) 
is remarkably free of untoward reactions. Daytime drowsiness 
(has not been reported. Rare allergic or idiosyncratic reactions 
imay occur, generally developing after 1-4 doses of the drug. 

Contraindications: Previous allergic or idiosyncratic reactions 
I to meprobamate contraindicate subsequent use. 

Precautions: Should administration of meprobamate cause 
^drowsiness or visual disturbances, the dose should be reduced. 
'Operation of motor vehicles or machinery or other activity 
requiring alertness should be avoided if these symptoms are 
present. Effects of excessive alcohol may possibly be increased 
by meprobamate. Prescribe cautiously and in small quantities 


to patients with suicidal tendencies. Massive overdosage may 
produce lethargy, stupor, ataxia, coma, shock, vasomotor and 
respiratory collapse. Consider possibility of dependence, par- 
ticularly in patients with history of drug or alcohol addiction; 
withdraw gradually after prolonged use at high dosage. 

Complete product information available in the product pack- 
age, and to physicians upon request. 

Usual adult dosage: One 400 mg. capsule or two 200 mg. 
capsules at breakfast; repeat with evening meal. 

Supplied: ‘Meprospan’-400 (meprobamate 400 mg.), ‘Mepro- 
span’-200 (meprobamate 200 mg.), each in sustained-release 
capsules. Both potencies in bottles of 30. 


CMC-760 


WALLACE LABORATORIES © Cranbury, N. J. 




C. G. STAUFFACHER, M.D., Secretary 


Missouri Academy of General Practice 


Committees for the ensuing year have been 
appointed by the President of the Missouri Acad- 
emy of General Practice, Edson C. Carrier, Kan- 
sas City. The Committees follow: 

Education: A. G. Karraker, Farmington, Chair- 
man; William Rost, St. Joseph; Paul Roberts, 
Sweet Springs; Benjamin Eisenmann, New 
Haven; Lester Wolcott, Columbia; A. J. Graves, 
Mt. Vernon; Walter Stelmach, Kansas City; 
Charles Ladd, St. Louis; Wyeth Hamlin, Han- 
nibal. 

Hospital: Walter Gray, St. Louis, Chairman; 
John M. Haight, Kansas City; William O. L. Sea- 
baugh, Cape Girardeau; Scott Benson, St. Joseph; 
Earl D. Russell, Springfield; Donald Shull, Jeffer- 
son City; Thomas Fischer, Hannibal. 

Finance: C. G. Stauffacher, Sedalia, Chairman; 
Wilbur A. Mullarky, St. Louis; Chester Peck, 
Kennett. 

Nominating: Walter T. Gunn, St. Louis, Chair- 
man; Cecil G. Leitch, Blue Springs; W. J. Shaw, 
Fayette. 

Medico-Legal: C. A. McBurney, Slater, Chair- 
man; Kenneth Knabb, Springfield; Luke A. 
Knese, St. Louis; Lawrence Epple, Mexico; Her- 
bert Rudi, St. Louis; Eugene Robichaux, Ex- 
celsior Springs. 

Publication: Barney Finkel, St. Louis, Chair- 
man; Walter T. Gunn, St. Louis; C. G. Stauf- 
facher, Sedalia; Roy W. Pearse Jr., Nevada; 


Ernest Schaper, St. Louis; William F. Shaw, 
Fayette; William Allen, Columbia; Lois Wyatt, 
Kirkwood; Robert Myers, Kansas City; John P. 
Mabrey, Plattsburg. 

National Defense: Carl Siegel, Sedalia, Chair- 
man; Foster Whitten, Carthage; B. A. Moran- 
ville, Columbia; Robert Kieber, St. Joseph; Mer- 
rill Gentry, Springfield; C. R. McAdam, St. 
Louis; Ivan Lloyd, Independence; John Walter- 
scheid, Hannibal; Lyman D. Brown, Springfield. 

Membership: P. C. Hall, St. Louis, Chairman; 
James Downey, Kansas City; Glen Elliott, Kan- 
sas City; Elmer Stegman, Raytown; Leo Wacker, 
St. Louis; Vernon E. Michael, St. Louis; Manning 
E. Grimes, St. Joseph; Donald R. Patterson, Jop- 
lin; David Hall, Springfield; Gordon Nunnelly, 
Cape Girardeau; Sherwood Baker, Columbia; 
Merrill Roller, Hannibal; M. K. Underwood, 
Rolla; Bobby M. McLain, Poplar Bluff; William 
Fair, Chillicothe; Samuel C. Bonney, Washing- 
ton. 

Public and Professional Relations: Edward 
Campbell, Cape Girardeau, Chairman; Vernon 
Wilson, Columbia; Arch Spelman, Smithville; 
B. J. Bass, Salem; Charles Worley, Sweet Springs; 
James Sweiger, Maysville. 

Representative to AAGP Mental Health Com- 
mission: Cecil Leitch, Blue Springs. 

Advisory: Roy W. Pearse, Nevada, Chairman; 
all past presidents, members. 


MISSOURI STATE MEDICAL ASSOCIATION 
1 06th Annual Session 
Hotel Chase-Park Plaza, St. Louis 
March 8, 9, 10,11, 1964 


10 


ADVERTISEMENTS 


13 



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by check, as you prefer. 

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Woman’s Auxiliary 





In November, I visited St. Joseph and attended 
a luncheon meeting of the Buchanan County 
Auxiliary. They were working on their usual 
large donation to AMAERF, selling the writing 
paper and playing cards and that day sent five 
dollars to IHA in my honor. The next day, I 
went to Chillicothe for dinner with the mem- 
bers of the Grand River 
Society and Auxiliary. 
Afterward, the Auxiliary 
held their business meet- 
ing and we discussed the 
recent Fall Conference 
and this year’s programs. 
The members are work- 
ing on IHA in their own 
towns by collecting and 
shipping sample medi- 
cines. The following week, 
I went to New Orleans 
for the Southern Medical Association meeting. 
We are all very proud that one of our past presi- 
dents, Ruth Kelling, was installed as President- 
Elect of the Southern Auxiliary. Missouri was 
well represented and it was a pleasure to see so 
many friends. 

Even though the doctors have extended lives 
with better care and drugs, there is a great need 
for knowledge of the proper care of senior citi- 
zens. The AMA’s interest in the improvement of 
nursing home standards with proper accredita- 
tion is a step in the right direction, but the pub- 
lic needs to be informed and trained also. My 
mail has brought information on two approaches: 
Two hospitals in Illinois are giving eight weeks 
training to student nurses in rehabilitation of 
chronically ill patients. The girls spend time in 
practical clinic instruction in the daily care of 


older rehabilitation patients in the nursing home 
and attend clinical conferences giving them 
much-needed experience in the care of older 
patients. The National Society for Crippled Chil- 
dren and Adults has recently published a safety 
check-list available free to the public and es- 
pecially designed for persons over 65 and their 
families. This publication attempts to make 
these persons aware of accidents which can oc- 
cur in the home and offers help in avoiding them. 
Copies of the “Safety Check-list for the Aging 
and the Handicapped and Their Families” may 
be obtained from Easter Seal affiliates or the Na- 
tional Society for Crippled Children and Adults, 
2023 W. Ogden Ave., Chicago 12, 111. Perhaps 
some of our auxiliaries would like to send for 
copies of the check-list and and use it in con- 
nection with a program on Safety or Rural 
Health. 

At our recent state Fall Conference, our speak- 
er, Mrs. Aaron Margulis, AMA Field Representa- 
tive for Women’s Organizations, mentioned many 
groups that have similar health programs and 
areas of interest with whom we might have a 
cooperative relationship. She has sent the list of 
these organizations to our officers and county 
presidents and I hope it will be of help to the 
various auxiliaries in planning programs with 
other groups in their communities. 

In view of the tragic event in Dallas, we have 
no way of telling what the legislative picture 
will be in the coming months, but we would as- 
sume that in the near future regular business 
will be resumed and we will again be taking up 
where we left off. Certainly, there will be some 
changes in the coming months; let us hope that 
the free enterprise system that we are fighting 
for will prevail. 



Mrs. L. S. Crispell 


14 



Volume 61, Number I — January, 1964 


Missouri Medicine 

JOURNAL OF THE MISSOURI STATE MEDICAL ASSOCIATION 

Copyright, 1963 by Missouri State Medical Association. All Rights Reserved. 


ANDREW L. HAHN, M.D., Springfield 

Systemic Lupus Erythematosus Associated 
With Procainamide Therapy 


A recent report by Ladd 1 described a case of 
a syndrome indistinguishable from systemic 
lupus erythematosus, with strongly positive L.E.- 
cell preparation, occurring during therapy with 
procainamide hydrochloride. All of the symp- 
toms subsided and the L.E.-cell preparation be- 
came negative after the drug was withdrawn. In 
the case to be presented induction of lupus by 
procainamide was suspected, but the relation- 
ship could not be proven because it was not pos- 
sible to withdraw the drug. Ladd’s report increas- 
es the likelihood that a relationship existed. 

Case Report 

The patient was first seen on September 16, 1957, 
at the age of 65, with severe chest pain due to 
massive acute posterior myocardial infarction. Forty- 
eight hours after admission he had a second bout of 
rather severe pain and went into shock; continuous 
intravenous norepinephrine administration was re- 
quired for the next seven days. Quinidine was given 
prophylactically from the time of admission in a 
dose of 0.2 gram every six hours. On September 
23, because of the appearance of basal rales, digi- 
talis therapy was begun. A few hours after the 
initial dose of 0.8 mg. of digitoxin the patient de- 
veloped atrial fibrillation. Since the ventricular rate 
was not abnormally rapid no vigorous effort to re- 
establish sinus rhythm was made immediately, but 
quinidine was increased to 0.2 gram every four 
hours. It was planned to attempt conversion to sinus 
rhythm when his general condition had improved. 
On September 29, however, without any change in 


therapy, he reverted to sinus rhythm. On October 
17 atrial fibrillation recurred. Quinidine was in- 
creased to 0.4 gram every two hours and after the 
third dose sinus rhythm was reestablished. There- 
after convalesence was uneventful. He was dismissed 
on October 24, 1957, on digitoxin 0.15 mg. daily 


A case is presented in which a syndrome 
indistinguishable from systemic lupus ery- 
thematosus and characterized by a strongly 
positive L.E. cell preparation occurred dur- 
ing procainamide hydrochloride therapy. 
It is the second such case to be described. 

Dr. Hahn is with the Glenn-Turner-Webb 
Medical Clinic, Springfield. 


and quinidine sulfate 0.4 gram t.i.d., as well as di- 
cumarol and phenobarbital. 

He was readmitted on November 18, 1957. One 
week earlier he had had an episode of unconscious- 
ness, occurring while sitting in a chair, lasting a few 
minutes. Since then he had had persistent postural 
dizziness, dyspnea and precordial distress; being an 
excessively stolid individual, he did nothing about 
this for a week. On admission he had ventricular 
tachycardia with a rate of 150. The patient and his 
wife were both definite in stating that he had been 
taking quinidine as instructed. This drug was there- 
fore discontinued and he was started on procain- 
amide (Pronestyl®) 0.5 gram every three hours. 
The following morning the ventricular tachycardia 


19 


20 


SYSTEMIC LUPUS ERYTHEMATOSUS— HAHN 


Missouri Medicine 
January, 1964 


remained but the rate had slowed to 126. That eve- 
ning he had a normal sinus rhythm, and procaina- 
mide was reduced to 0.25 gram every three hours. 
On November 24 the ventricular tachycardia re- 
curred; increasing procainamide to 0.5 gram every 
three hours brought about conversion to sinus 
rhythm overnight. The maintenance dose was now 
increased to 0.5 gram every four hours, but on No- 
vember 26 he again had ventricular tachycardia. 
Only when the maintenance does was continued at 
0.5 gram of procainamide every three hours did the 
episodes cease to occur. On December 9 he com- 
plained of painful swelling of the left wrist; there 
was a minimal increase in local heat and the joint 
had a slightly bluish appearance. At first this was 
thought to be a hemarthrosis, but it subsided com- 
pletely in five days. He was dismissed on Decem- 
ber 18, 1957, feeling generally well. However, fur- 
ther transient episodes of ventricular tachycardia 
occurred at home and procainamide dosage was 
increased to 0.5 gram every two hours during the 
day and every three hours at night. On this dosage 
the episodes became quite rare and the only per- 
sistent arrhythmia was due to occasional ventricular 
premature contractions. 

In late August 1958 he was hospitalized with acute 
pleurisy with a small effusion. He had been fishing 
on August 26 and became chilled in a cold wind. 
The next day he awoke with severe pleuritic left 
chest pain. On August 29, when he first sought at- 
tention, there was a small effusion in the left base. 
He had a recurrent episode of ventricular tachy- 
cardia on the day of admission. Laboratory studies 
showed a hemoglobin of 13.4 grams and white 
blood count of 7,400 with normal differential. The 
pain and effusion subsided within a week and he 
was dismissed. 

In the following weeks he developed marked 
anorexia, weight loss, weakness and migratory joint 
pains. Erythrocyte sedimentation rate, which in 
May had been 8 mm. at 30 minutes and 14 mm. at 
one hour (Cutler), rose to 18 at 30 minutes and 22 
at one hour. Serum protein determination showed 
an albumin of 3.12 and globulin of 4.58. He was 
hospitalized in October 1958 for further study. 
White blood count at that time was 3,000 with nine 
eosinophils, 49 segmented neutrophils, 39 lympho- 
cytes, and seven monocytes. An L.E.-cell prepara- 
tion was strongly positive, numerous typical cells 
being seen in every field. He had a mild anemia 
(hemoglobin 11.3 grams, hematocrit 34 volumes 
per cent) and an elevated indirect-reacting serum 
bilirubin (3.0 mg.) with normal direct-reacting bili- 
rubin. 

He was started on adrenal steroid in the form of 
triamcinalone, 64 mg. daily in divided doses, later 
tapered off to 16 mg. daily, and had prompt im- 
provement in all respects; appetite and sense of 
well-being returned and joint pains disappeared. 
White blood count and differential, hemoglobin and 


bilirubin returned to normal. Procainamide was sus- 
pected of being a causative factor in his illness. 
Inasmuch as the first episode of tachycardia had 
occurred while he was on 1.2 grams of quinidine 
sulfate per day, it did not appear likely that this 
drug would control his arrthythmia. However, an 
attempt was made; procainamide was discontinued 
and quinidine reinstituted in a dose of 0.4 gram 
every three hours around the clock. Several days 
later he had an episode of ventricular tachycardia 
with rate of 150 and procainamide was restarted. 
The paroxysmal ventricular tachycardia was again 
well controlled. 

On continued steroid administration all of the 
manifestations of lupus remained in abeyance ex- 
cept the sedimentation rate, which remained ele- 
vated. For a year and one half the patient did quite 
well, with no episodes of tachycardia, and his pro- 
cainamide dose was gradually lowered to 0.5 gram 
five times daily. In April 1961 he had a severe epi- 
sode of ventricular tachycardia with shock, sinus 
rhythm being restored with intravenous procaina- 
mide. Following this episode he remained rather 
weak, though up and about. In October 1961 he ex- 
pired suddenly at his home. An autopsy was not 
obtained. 

Discussion 

At the time this case was studied there had 
been no reported instance of procainamide-in- 
duced systemic lupus erythematosus. I consulted 
the research department of the company manu- 
facturing the drug and was told that they knew 
of no such reaction to it. Since I was unable to 
observe the effects of discontinuing the drug, 
the suspected relationship of procainamide to 
the systemic lupus could not be further tested. 
Because of Ladd’s subsequent report of a case 
wherein lupus was shown rather convincingly 
to result from procainamide therapy, it now ap- 
pears highly probable that the lupus syndrome 
in the present case was likewise precipitated by 
procainamide. 

Summary 

A case is presented in which a syndrome in- 
distinguishable from systemic lupus erythema- 
tosus, and characterized by a strongly positive 
L.E.-cell preparation, occurred during procaina- 
mide hydrochloride therapy. This is the second 
such case to be reported. 

Addendum 

Since this case report w ? as submitted for pub- 
lication an additional case has been observed. 
Miss D.M., a forty-nine year old female with 
paroxysmal atrial tachycardia, continued to have 
(Continued an page 23) 


WALTER R. STAFFORD, M.D., and 
STEPHEN F. BOWEN JR., M.D., St. Louis 


Blowout Fractures of the Floor of the Orbit 


The purpose of this paper is to describe a condi- 
tion which has been designated as “blowout frac- 
ture” of the orbital floor. This type of injury oc- 
curs more frequently than is generally assumed. 
On routine examination the diagnosis is often 
missed because the fracture is either masked by 
the extent of the facial injury, or not suspected. 
If possible, the diagnosis should be made and 
treatment started early, as the oculomotor im- 
balances resulting from the fracture are more 
difficult to correct if the tissue in the orbit has 
become scarred down. 

Mechanism of Injury 

The contents of the orbit are protected by a 
strong bony rim composed of the supraorbital 
arch of the frontal bone superiorly, the frontal 
process of the maxilla medially, the zygoma and 
maxilla inferiorlv and the zygoma laterally. In 


A case report and discussion of an injury 
that is often hard to detect. 

Dr. Stafford, formerly Chief Resident in 
Ophthalmology at St. Louis University 
Hospitals, is now in the Ophthalmic Pa- 
thology Branch of the Armed Forces Insti- 
tute of Pathology, Washington, D. C. Dr. 
Bowen is an Assistant in the Ophthalmology 
Department, St. Louis University, School 
of Medicine. 


the posterior half of the orbital floor, immedi- 
ately anterior to the inferior orbital fissure, is an 
area of rather thin bone (measuring only 0.5 mm. 
to 1.0 mm. in thickness). This area is weakened 
still more by the presence of the infraorbital 
canal. The shape of the orbit on cross section is 
that of a cone, and when the orbital contents 
are pushed backwards, as a result of trauma to 
the soft tissues of the anterior orbital area, there 
is a sudden rise in the intraorbital pressure. This 
increased internal pressure is transmitted to the 
walls of the orbit causing a “blowout” fracture 
of the weakest portion. 

By its definition, and in its most typical form, 


the fracture involves only the floor and not the 
orbital rim, following trauma over the orbital 
contents anteriorly by a non-penetrating object, 
such a a fairly large ball or a human fist. The 
globe is capable of withstanding considerable 
pressure without rupture, although severe inju- 
ries due to a smaller object, such as a golf ball, 
often do produce a rupture of the globe. 

Clinical Diagnosis 

The signs and symptoms of the blowout frac- 
ture are as follows: 

(1) Varying degrees of ecchymosis, edema of 
the orbital region and subconjunctival hemor- 
rhage. 

( 2 ) Diplopia, especially on upward gaze. 

(3) Varying degrees of enophthalmos, of 
which the patient may not be aware. 

(4) Hypoethesia, or anesthesia in the skin 
area of the cheek supplied by the infraorbital 
nerve. 

(5) Inability of the patient to rotate the in- 
volved eye upward in the normal range. 

( 6 ) Although routine orbital roentgenographic 
studies may be equivocal or negative, the roent- 
genogram of the maxilla in the Water’s view 
frequently shows a cloudy maxillary sinus (rep- 
resenting a hematoma), or a downward hernia- 
tion of the orbital contents. A laminogram may 
more clearly delineate the herniation of the or- 
bital contents. 

(7) Traction applied directly to the inferior 
rectus muscle under anesthesia may demonstrate 
that the globe cannot be rotated upward, due to 
incarceration of the muscle in the fracture. 2 

Case Report 

The following case report is given as an ex- 
ample to demonstrate some of the difficulties in 
making the diagnosis of blowout fracture of the 
orbit. 

A 16-year-old white male was seen in the emer- 
gency room on September 29, 1962, after being 
kicked in the region of the right eye during a foot- 
ball game four hours before admission. The patient 
noted moderate pain and diplopia immediately there- 
after. Examination revealed the patient’s vision to 
be right eye 20/15-1 and left eye 20/15-2. There 
was moderate ecchymosis and edema of the skin and 


21 


22 


BLOWOUT FRACTURES— STAFFORD AND BOWEN 


Missouri Medicine 
January, 1964 


subcutaneous tissue of the lids and periorbital tissue 
on the right. The conjunctivae, sclerae and corneae 
were not abnormal, save for moderate subconjuctival 
hemorrhage nasally and inferiorly in the right eye. 
The pupils measured right eye 3 mm. and left eye 
5 mm.; however, they reacted equally and briskly 
to light and on accommodation directly and con- 
sensually. The extraocular muscles showed a full 
range of motion, but Maddox Rod examination and 
cover test revealed 15 A right hypertropia and 4 A right 
extropia. The diplopia increased on looking superior- 
ly and the patient experienced pain on directing his 
gaze in this direction. There was a minimal enoph- 
thalmos; no area of dermal anesthesia or hypothesia 
could be delineated (fig. 1). Examination of the 



Fig. 1. Pre-operative appearance of patient. Note 
enophthalmos and position of corneal light reflex. 


media and fundi and slit lamp examination revealed 
no abnormalities. The right maxillary sinus did not 
transilluminate well and roentgenographic studies 
showed a relative widening of the bony component 
of the lateral roof of the right maxillary antrum, al- 
though the remainder of the sinus was radiograph- 
ically clear. No fracture site could be seen. The re- 
mainder of the physical examination and the lab- 
oratory studies revealed no other abnormalities. 

On October 1, 1962, under general anesthesia an 
exploration of the right maxillary sinus through a 
Caldwell-Luc approach (by Dr. W. B. Harkins of 
the Department of Otorhinolaryngology) and a right 
lateral anterior inferior orbitotomy were done, after 
traction on the inferior rectus muscle revealed no 
limitation of motion. The anterior maxillary sinus 
window was made approximately 1.5 cm. in di- 
ameter, the bone being removed in one piece with 
its periosteum intact, with the view of using this as 
a possible bone graft for the orbital floor. The sinus 
cavity was clear and mucous membrane lining in- 
tact; however, in the upper lateral portion of the 
sinus the mucous membrane bulged downward about 
2 mm. in what appeared to be a hematoma forma- 
tion. At the posterior end of this bulge and at the 
extreme posterior apex of the maxillary sinus, nu- 
merous small fragmented pieces of thin bone could 
be palpated. The lateral anterior inferior orbitotomy 
was then done; and the periosteum was separated 



Fig. 2. Appearance of patient 24 hours after surgery. 
Compare enophthalmos and position of corneal light 
reflex with fig. 1. 


from the bone of the orbital floor back to the posterior 
third of the orbit laterally where a small depression 
lateral to the infraorbital canal in the floor of the orbit 
could be felt. All orbital contents were lifted from the 
orbital floor to be sure that there was no incarcera- 
tion of tissue in the fracture site. Since orbital con- 
tents were not herniated into the sinus cavity no 
bone graft was placed. The orbitotomy was closed 
in separate layers and the nasal antral wall of the 
right maxillary sinus was opened into the nose under 
the inferior turbinate, and the sinus cavity firmly 
packed with plain gauze with the tail brought out 
through the nasal antral opening into the nose. 

At the first postoperative dressing change, 18 hours 
after the surgery, the patient had single binocular 
vision, and no tropia was demonstrable (fig. 2). The 
maxillary sinus pack was removed after 72 hours 
and the postoperative course was uneventful. The 
patient was discharged seven days after surgery with 
the single binocular vision, equal pupils, and no 
demonstrable tropia. 

Comment 

The most common site of the blowout fracture 
is in that portion of the orbital floor weakened 
by the infraorbital canal or groove. The inferior 
rectus muscle is situated immediately above the 
infraorbital canal on the undersurface of the 
orbital contents; the inferior oblique muscle 
arises from the orbital floor near the lateral mar- 
gin of the lacrimal groove. The two muscles are 
intimately fused at the point where the inferior 
oblique crosses beneath the inferior rectus. It is 
easily seen, therefore, that these two muscles are 
frequently involved in the blowout fracture. The 
incarceration of the inferior rectus muscle in the 
fracture site restricts the rotation of the globe in 
the field of action of the superior rectus. If the 
fracture is located laterally to the infraorbital 
canal, the inferior oblique and inferior rectus 
muscles may not be involved at all. Schjedlerup 
feels that most of the diplopias are caused by ad- 




Volume 61 
Number 1 


BLOWOUT FRACTURES—STAFFORD AND BOWEN 


23 


hesions or pinching of the orbital contents in 
the fracture lines. 5 

Injury to the motor nerves of the inferior 
oblique and inferior rectus muscles may also 
occur. Most commonly injured is the nerve to 
the inferior oblique muscle (a branch of the in- 
ferior division of the oculomotor nerve). This 
nerve courses along the lateral border of the in- 
ferior rectus muscle and enters the middle por- 
tion of the inferior oblique muscle. It is thus ex- 
posed to injury, while the relatively short course 
of the nerve to the inferior rectus muscle makes 
it less vulnerable to injury in the blowout frac- 
ture. Normal infraorbital nerve conduction indi- 
cates that the fracture site is either medial or 
lateral to the infraorbital canal. 

The escape of orbital fat and orbital contents 
through the defect in the orbital floor is the 
cause of the enophthalmos. 1 

Surgical exploration of the orbital floor is indi- 
cated whenever the diagnosis is questionable, 
and should be made through a Caldwell-Luc 
approach in the canine fossa. The opening 
should be large enough to allow direct inspection 
and palpation of the orbital floor. If a fracture is 
found, the orbit should be entered and all orbital 
contents freed up from the fracture site. The ex- 
tent of injury found at operation is usually much 
greater than the roentgenographic findings indi- 
cate. 1 ’ 2 Several methods have been proposed for 
the treatment of blowout fractures of the orbit. 
Basically these consist of freeing the orbital 
contents from the fracture site, re-establishing 
the orbital floor and supporting it while the 
bone heals. 1 ’ 2 ’ 3 * 4 


Summary 

A blowout fracture of the floor of the orbit 
can be produced by external trauma to the front 
of the eye resulting in an increased intraorbital 
pressure herniating the orbital soft tissues 
through the weakest area of the orbital floor. 
Findings associated with such an injury are 
signs of acute trauma, diplopia on upward gaze, 
varying degrees of enophthalmos, hypoesthesia 
or anesthesia of the skin along the distribution 
of the infraorbital nerve, and limited upward 
rotation of the globe. Roentgenography, especial- 
ly laminography, is helpful in the diagnosis, 
however the extent of injury is often greater than 
that shown by X-ray. A precise diagnosis is only 
established by exploration of the orbital floor by 
the Caldwell-Luc approach and inferior orbi- 
totomy. The present methods of treatment are re- 
viewed. 

We feel, as do Cunningham and Marden, 2 
that if the blowout fracture is diagnosed early 
before adhesions form, good results can often be 
obtained with reduction of the fracture and 
antral packing. 

Bibliography 

1. Converse, J. M. and Smith, B. : Blowout Fracture of the 
Floor of the Orbit. Trans. Amer. Acad. Ophthal. and Otolaryng. 
64:676-688, 1960. 

2. Cunningham, J. D. and Marden, P. A.: Blowout Fractures 
of the Orbital Floor. Archives of Ophthal. 66 :492-497, 1962. 

3. Fisher, D. F. : Discussion on Smith, B. and Converse, J. M. : 
Early Treatment of Orbital Floor Fractures. Trans. Amer. 
Acad. Ophthal. and Otolaryng. 61 :602-608, 1957. 

4. Neely, J. C. : Treatment of Traumatic Diplopia. Brit. J. 
Ophthal. 31:581-642, 1947. 

5. Schjederup, H. : Some Considerations Concerning Traumatic 
Diplopia. Acta Ophthal. 28:377-391, 1950. 


SYSTEMIC LUPUS ERYTHEMATOSUS 

(Continued from page 20) 

episodes of tachycardia on digitalis and seda- 
tion. She could not tolerate even small doses of 
quinidine because of occurrence of nausea and 
vomiting. Procainamide was started on June 21, 
1963 in a dosage of 250 mg. q.i.d. The episodes 
of tachycardia became less frequent and less pro- 
longed but early in August she developed the 
following symptoms: Episodes of hives, with 
one or several urticarial lesions described as the 
size of the eraser on a lead pencil occurring two 
or three times daily on various areas of the body 
and lasting for a few minutes to an hour or 
more; stiffness in the neck, forearms, and hands; 
weakness of the hands noted when trying to 
wring out a wash rag; edema of the finger joints; 
moderate malaise. She had no chills or fever. 
Laboratory examination revealed the following: 
Blood sedimentation rate, which had been five 
at thirty minutes and eleven at one hour in Janu- 


ary of 1963, was now twelve at thirty minutes 
and twenty at one horn. Hematocrit was stable. 
WBC had been 9,350 in November 1961 and was 
now 4,900 with 16 stabs, 59 segs, 22 lymphs, and 
3 monocytes. L.E. cell preparation was positive. 
Procainamide w^as discontinued on August 9 
and her symptoms gradually subsided over a 
period of about two weeks. In the following two 
weeks she had some occasional mild recurrence 
of joint stiffness or soreness and hives but since 
early September there has been no further recur- 
rence of any of these symptoms. On September 
5 her sedimentation rate w r as 5 at thirty minutes 
and 12 at one hour, WBC 5,700 with 5 stabs, 61 
segs, 23 lymphs, 9 monocytes, and 2 eosinophils. 
Repeat L.E. cell preparation on September 17 
was negative. Procainamide has not been re- 
administered. 

Bibliography 

1. Ladd, A. T. : Procainamide-Induced Lupus Erythematosus, 
New England J. Med. 267:1357-1358, 1962. 


G. K. KENNARD, M.D., R. A. TWYMAN, M.D., and 
R. E. ALLEN, M.D., Kansas City 


Ovarian Metastases From Carcinoma 
Of the Colon 


Metastasis from adenocarcinoma of the 
colon to one or both ovaries occurs in from 
2 to 8 per cent of some reported surgical se- 
ries. The bulky ovarian metastases frequent- 
ly require a secondary palliative opera- 
tion. This can be prevented by prophylac- 
tic castration at the time of the original 
colon resection. Three cases of this com- 
plication are presented which occurred dur- 
ing a period of one year. It is strongly 
recommended that oophorectomy be done in 
all postmenopausal female patients, and in 
those premenopausal patients who fulfill 
certain criteria. 

The three authors are on the surgical ser- 
vice of St. Luke’s Hospital, Kansas City, 
and Dr. Kennard is also on the surgical ser- 
vice of St. Mary’s Hospital, Kansas City. 


Our attention was focused upon the problem 
of ovarian metastases from carcinoma of the 
colon by the occurrence of this complication in 
three patients on our service within the period of 
one year. Two of these women presented with 
large pelvic tumors ten months and eight months, 
respectively, following the primary bowel re- 
sections. It seemed probable, in retrospect, that 
occult ovarian metastases represented the only 
spread of the disease at the time of the original 
operation. Of course, implantation caused by the 
manipulation of viscera at the time of surgery 
cannot be ruled out. In either case, the signifi- 
cant inference is that a secondary palliative op- 
eration might have been avoided had prophylac- 
tic castration been performed at the time of 
colon resection. It is even more chastening to 
consider the possibility that a long term survival 
or cure might have been achieved in the two 
patients whose ovarian tumors appeared later, 
since, at their second operations, both revealed 
no evidence of spread other than to ovaries. The 
peritoneal implants present in both cases seemed 


to be secondary to erosion through the ovarian 
tumor capsules. 

Case Reports 

Case 1. A 39 year old white female was admitted 
to St. Luke’s Hospital April 11, 1961, with the chief 
complaint of increasing number of bowel move- 
ments, of a dark color, of several weeks’ duration. 
Her past history included multiple operations; i.e., 
appendectomy in 1940; excision of benign breast 
tumor, 1947; cholecystectomy for gall stones, with 
synchronous excision of intraductal papilloma, left 
breast, 1959; and cystocele and rectocele repair in 
November 1960. A barium enema was done on this 
admission, revealing a constricting lesion of the 
recto-sigmoid colon. Biopsy confirmed the diag- 
nosis of adenocarcinoma. At operation, April 17, 

1961, anterior resection of the sigmoid colon, with 
primary anastomosis, was performed. The liver was 
free of metastasis. No specific note was made of the 
condition of the pelvic organs, but they were, pre- 
sumably, grossly normal, since the surgery was in 
that field. The pathologist reported a Dukes’ Stage 
C adenocarcinoma of the colon. Her postoperative 
course was complicated by small bowel obstruction 
due to adhesions, requiring a second laparotomy, 
from which she recovered uneventfully. She was 
dismissed from the hospital on May 10, 1961. 

Her next admission, February 19, 1962, was for 
a chief complaint of abdominal distention of about 
two weeks’ duration, accompanied by constipation. 
Examination revealed a large lower abdominal and 
pelvic mass extending to above the umbilicus. At 
laparotomy on February 21, bilateral ovarian car- 
cinoma with peritoneal implants were found. There 
were no gross liver or omental metastases. A seg- 
ment of ileum adherent to the tumor was resected 
also, and anastomosis performed; the pathologist 
reported adenocarcinoma of both ovaries. Following 
our experience with the next two cases to be de- 
scribed, the slides on this case were reviewed, and 
it was apparent that the tumor in the ovaries was 
identical histologically with that previously removed 
from the colon. 

The postoperative course following this procedure 
was uneventful, but she was readmitted October 18, 

1962, with intestinal obstruction. This did not re- 
spond to long tube decompression, so another lapa- 
rotomy was undertaken on October 27, revealing 


24 


Volume 61 
Number 1 


OVARIAN METASTASES — KENNARD ET AL. 


25 


pelvic carcinomatosis, involving the ileum. A di- 
verting ileocolostomy was done. The postoperative 
course was complicated by “surgical mumps” of the 
submandibular salivary glands, fecal fistula, and 
finally death on December 17, 1962. Autopsy re- 
vealed no gross tumor mass in the pelvis, but dif- 
fuse peritoneal bowel implants, and a metastatic 
nodule in the lower lobe of the right lung. The 
liver was free of metastases. 

Case 2. A 46 year old white female was admitted 
to St. Luke’s Hospital August 19, 1962. She com- 
plained of pain in the right side of the upper ab- 
domen, often worse after eating, and increasing 
fullness in the lower abdomen, of three to four 
weeks’ duration. She attributed these symptoms to 
an automobile accident two months previously in 
which she had sustained mild trauma to the lower 
right chest and abdomen. A barium enema showed 
a constricting lesion in the right transverse colon, 
and pelvic examination disclosed huge pelvic tumors 
extending up to about the level of the umbilicus. 
The preoperative diagnosis of carcinoma of the 
transverse colon, with probable ovarian metastasis, 
was made. This was confirmed at laparotomy on 
August 23, 1962, at which time huge ovarian me- 
tastases with peritoneal implants were found and 
a constricting lesion of the transverse colon invad- 
ing onto the serosa of the bowel wall. There were 
also two metastatic nodules in the right lobe of the 
liver. A wedge resection of the transverse colon 
bearing the tumor was accomplished and primary 
anastomosis done. Then a panhysterectomy was 
performed, removing the large ovarian masses and 
uterus. The pathologist reported a Dukes’ Stage C 
adenocarcinoma of the colon with metastases to 
both ovaries and peritoneum. Her recovery from 
operation was uneventful, and this patient was alive 
and apparently in good health 11 months after the 
operation. 

Case 3. A 50 year old white female was admitted 
to St. Luke’s Hospital September 22, 1962, with the 
complaints of abdominal pain of about seven weeks’ 
duration, constipation for one week, and vomiting 
for the preceding three days. Past history revealed 
appendectomy many years previously, uterine sus- 
pension with tubal ligation in 1940, and facial trau- 
ma from an automobile accident two years prior to 
this admission. She was treated by intravenous 
fluids, long intestinal tube and other supportive 
measures. Barium enema revealed an apparently 
complete obstruction of the colon at the splenic 
flexure. However, she was able to be decompressed, 
and the bowel prepared for primary resection and 
anastomosis, which was done on September 27, 
1962. There were no palpable liver metastases, and 
the pelvis was normal to palpation. The pathologist 
reported Dukes’ Stage C adenocarcinoma of the 
colon. 

Her second admission, to St. Mary’s Hospital, 
Kansas City, on May 23, 1963, was for complaints 


of lower abdominal fullness and feelings of pressure 
in the pelvis of several weeks’ duration. Examination 
revealed a large mass arising in the pelvis and ex- 
tending nearly to the umbilicus. Laparotomy was 
performed on May 24, finding huge ovarian tumors, 
eroding through their capsule and invading and im- 
planting onto pelvic peritoneum. Bilateral salpingo- 
oophorectomy was done. Palpation of the liver re- 
vealed no metastases there, and the area of previous 
colon anastomosis appeared free of disease. Her post- 
operative course was uneventful. Radioactive gold 
was instilled intraperitoneally on the ninth postoper- 
ative day, and she was dismissed three days later. 
The follow-up on this patient is only two months at 
this writing, but the prognosis is, of course, con- 
sidered poor. 

In the medical literature of recent years there 
are numerous articles relating to clinical and ex- 
perimental work on malignant neoplasms of the 
colon and rectum. The objective of these studies, 
explicit or implicit, is an ultimate improvement 
in long term survival rates. Yet, a majority of 
recognized authorities in this field make little or 
no mention of prophylactic oophorectomy in fe- 
male patients as being a significant contribution 
toward this goal. 1-4 It was our impression, prior 
to our experience with the three cases reported, 
that ovarian metastasis from colon carcinoma was 
an extremely rare occurrence. This would seem 
to be confirmed by several statistical studies, of 
large series of cases, in which no mention is made 
of such a complication. 5-8 

On the other hand, a number of authors have 
reported experiences similar to ours, and con- 
sider this to be a problem worthy of serious con- 
sideration. Sherman, et al, 9 reported eight cases, 
of either concomitant or subsequent ovarian 
metastases in a series of 162 female patients un- 
dergoing resection of the colon or rectum, from 
1953 to 1962, an incidence of 5 per cent, and 
urged consideration of prophylactic oophorec- 
tomy in such patients. Willis 10 recommends thor- 
ough examination of the ovaries before resection 
of any abdominal viscus for carcinoma. Burt, 11 
in 1951, studied 17 patients with metastatic 
ovarian carcinoma from a series of 493 female 
patients undergoing resection of primary lesions 
in the colon and rectum, together with one ad- 
ditional private case. He concluded that all such 
patients over the age of 40 should have the bene- 
fit of prophylactic oophorectomy. In 1960, he 12 
reiterated this position and stated that an ad- 
ditional 20 cases had been seen at the Presby- 
terian Hospital, New York, since 1949. Wheelock 
and Putong, 13 in studying 68 cases of cancer, 
metastatic to ovaries, found 26 of them were from 


26 


OVARIAN METASTASES— KEN NARD ET AL. 


Missouri Medicine 
January, 1964 


primary carcinomas in the colon and rectum. And 
Abrams, et al 14 reported that in 118 consecutive 
autopsies of women dying of carcinoma of the 
colon, excluding the rectum, 16 presented with 
ovarian metastases, 13.6 per cent. Deddish and 
Stearns 15 reporting their experience with ex- 
tended abdomino-pelvic lymph node dissection 
for carcinoma of the left colon and rectum, to- 
gether with bilateral oophorectomy in all female 
patients, found 8 per cent of 63 women to have 
metastases in the ovaries. 

And, finally, Rendleman and Gilchrist, 16 in 
1959, reported encountering 11 cases of ovarian 
metastasis from cancer of the colon or rectum 
during the preceding 10 years. During the six 
year period prior to their report, they had fol- 
lowed specific criteria for performing bilateral 
oophorectomy at the time of colon resection. 
These criteria were: (1) one or both ovaries 
adherent to the tumor; (2) either, or both, 
ovaries grossly abnormal; (3) tumor invading 
the serosa of the bowel, or the presence of peri- 
toneal implants; (4) all palliative resections, 
excepting the “frozen pelvis.” Of 102 cases of 
carcinoma of the gastrointestinal tract in female 
patients, during these six years, 42 were found 
to fulfill these criteria. Of this number three or 
2.9 per cent, revealed ovarian metastases. They 
considered of most significance the fact that 
none of the 102 patients had required a second 
palliative laparotomy during the follow-up pe- 
riod. 

Discussion 

In reviewing the experiences of these and 
other authors, 17, 18, 19 and relating them to our 
own small series, the following points seemed 
worthy of emphasis. 

1. In most instances, patients presenting the 
complication of ovarian metastases had primary 
tumors of the colon or rectum which had pene- 
trated the thickness of the bowel wall (Dukes’ 
Stage B or C ) . This implies that the most likely 
route of spread is by direct seeding or implanta- 
tion of cells onto the ovary. 

2. In many instances reported, small ovarian 
implants were found microscopically that had 
been unsuspected on gross inspection. 

3. On the other hand, as in our case 2, rapidly 
enlarging, bulky pelvic tumors are often the 
presenting complaint before the colon tumor be- 
comes symptomatic. Therefore, the true primary 
tumor may be overlooked unless it is suspected 
or searched for. 

4. In a great many cases, the ovaries seem to 
be the only, or at least the major, site of meta- 


static involvement. This suggests a generalized 
host resistance to the tumor, with a localized 
susceptibility of the ovary to tumor implants. 

5. When it occurs following colon resection, 
ovarian metastasis usually presents as a bulky 
tumor, which is of clinical importance in that 
another laparotomy is often indicated for pallia- 
tion. 

6. Statistically, colon carcinoma is more com- 
mon in the older age groups. However, these 
cases presenting with ovarian metastases are fre- 
quently premenopausal. 

7. The prognosis, once ovarian metastasis has 
occurred, is poor, with an average survival time 
in the neighborhood of one year. 

Conclusion 

Metastatic involvement of the ovaries by car- 
cinoma of the colon and rectum is uncommon, 
but not rare, occurring in 2 to 8 per cent of re- 
ported surgical series. Therefore, in the continu- 
ing effort to improve salvage rates by surgical 
attack on colon cancer, we feel strongly that the 
following tenets should be adopted as basic 
principles by all surgeons performing colon sur- 
gery. 

( 1 ) All female patients undergoing primary 
colon resection for adenocarcinoma, who are 
postmenopausal, should have synchronous bi- 
lateral oophorectomy performed also. 

( 2 ) Any female patient who is premenopausal, 
and operated upon for cancer of the colon or 
rectum, should be evaluated according to the 
criteria outlined by Rendleman and Gilchrist, 
as previously noted. 

(3) Any patient presenting with an ovarian 
cyst or tumor as the primary problem should 
have a thorough workup of the gastrointestinal 
tract to exclude the possibility that the ovarian 
tumor represents metastasis from a primary neo- 
plasm of the gastrointestinal tract. 

Summary 

1. Three cases are presented of women mani- 
festing ovarian metastases from carcinoma of 
the colon. 

2. A brief review of the current literature is 
presented to illustrate that some, but not the 
majority of authorities in this field, consider this 
complication of some significance. 

3. Certain pertinent points worthy of emphasis 
have been enumerated. 

4. A “modus operandi” is suggested for sur- 
geons dealing with patients in this category. 

(Continued on page 29) 


HERBERT L. WARRES, M.D., Springfield 


Use of Nalidixic Acid in the Treatment of 
Urinary Tract Infections 


A new naphthyridine derivative, nalidixic acid/ 
in preliminary animal and clinical trials has dem- 
onstrated efficacy in the treatment of urinary 
tract infections. 1, 2> 3 Further studies to ascertain 
its effectiveness and toxicity seemed desirable. 

Method and Materials 

This investigation can be divided into two 
parts. First, routine urine cultures, and, when 
positive, in vitro sensitivity tests were made upon 
all patients undergoing cystoscopic examination. 
Secondly, in a limited number of these patients 
nalidixic acid was administered and its clinical 
efficacy and toxicity studied. 

Culture was performed by adding urine to 
blood agar and eosin-methylene-blue media. Or- 
ganisms recovered were then transferred to an- 
other blood agar and Meuller-Hinton plate, heav- 
ily cross-streaked and medium strength antibiotic 
disks for chloramphenicol, erythromycin, nitro- 
furantoin, kanamycin, neomycin, novobiocin, 
penicillin, polymixin, colistin, streptomycin, sulfa- 
methizole, tetracycline, demethylchlortetracy- 
cline and nalidixic acid in 5, 30, and 60 meg. 
strengths were used. Sensitivity studies against 
this latter drug were not done in nine patients 
to whom this drug was subsequently adminis- 
tered. In vitro sensitivity studies were not per- 
formed in three cases despite positive cultures. 
The dosage schedule used was 0.5 gm. nalidixic 
acid four times daily except as otherwise noted. 

Results 

Eighty-eight positive urine cultures were ob- 
tained in 80 patients. Organisms cultured are 
listed in table 1. Table 2 summarizes the in vitro 
results. By totaling the positive and negative 
results, the actual number of sensitivity tests 
performed for each antibiotic drug can be ob- 
tained. Resistance to all antibiotics was dem- 
onstrated in Pseudomonas 1 and E. coli 1. Where 
sensitivity studies to nalidixic acid were done, 
Pseudomonas 6, Aerobacter 2, and E. coli 1 
were resistant to all concentrations. 

* Negram, brand of nalidixic acid (Research No. Win 
18,320), was supplied through the courtesy of the Department of 
Medical Research, Winthrop Laboratories, N. Y. 


Nalidixic acid was administered to 26 patients 
whose ages varied from 3 to 85 years, average 
60. Seventeen were male, nine female. Bacteria 
obtained upon culture in these patients were: 
Pseudomonas 14, E. coli five, Aerobacter three, 


Dr. Warres is Clinical Assistant Professor 
of Surgery (Urology), Department of Urol- 
ogy, University of Missouri. 


Proteus one and unidentified Gram negative 
rod one. Negative urine cultures were obtained 
in two despite marked pyuria accompanied by 
chills and fever. 

These patients were subdivided into four cate- 
gories for the purposes of this study. Category 1 
comprising five patients was essentially that of 
an acute illness. Two were women with acute 
cystitis with positive cultures for E. coli, one of 
whom failed to respond to sulfamethizole, and 
both showing prompt clinical improvement and 
conversion to normal urinalysis upon nalidixic 
acid. The other three patients had febrile reac- 
tions post-prostatic transurethral resection ac- 
companied by pyuria. One had a negative urine 


CHART 1 

ORGANISMS ISOLATED FROM PATIENTS WITH 
URINARY TRACT INFECTIONS 




Without 



No. 

Sensi- 

Repeat 

No. 

Cul- 

tivity 

Cultures 

Pts. 

tures 

Studies 

2 3 4 


Pseudomonas 38 42 2 1 0 1 

E. coli 22 26 0 2 1 0 

Aerobacter 13 13 1 0 0 0 

Proteus 4 4 0 0 0 0 

Unident G. neg. 

rod 2 2 0 0 0 0 

Unident G. neg. 

diplococcus .... 1 1 0 0 0 0 

Total 80 88 — — — — 


27 


28 


NALIDIXIC ACID—WARRES 


Missouri Medicine 
January, 1964 


CHART 2 


IN VITRO SENSITIVITY TESTS PERFORMED ON GRAM NEGATIVE 
ORGANISMS ISOLATED FROM URINARY TRACT INFECTIONS 


Pseudomonas 
Pos. Neg. 

E. 

Pos. 

coli 

Neg. 

Aerobacter 
Pos. Neg. 

Proteus 
Pos. Neg. 

Unident. 
G. neg. rod 
Pos. Neg. 

Unident. G. 
neg. 

diplococcus 
Pos. Neg. 

Chloramphenicol 

17 

21 

13 

16 

5 

6 

1 

2 

1 

1 

0 

0 

Erythromycin 

0 

37 

0 

25 

0 

11 

0 

3 

0 

2 

0 

0 

Nitrofurantoin 

9 

28 

14 

8 

4 

5 

0 

4 

0 

1 

1 

0 

Kanamycin 

. 13 

27 

19 

7 

6 

6 

2 

2 

1 

1 

1 

0 

Neomycin 

11 

25 

11 

13 

5 

5 

1 

2 

1 

1 

0 

0 

Novobiocin 

0 

35 

1 

24 

0 

11 

0 

3 

0 

2 

0 

0 

Penicillin 

0 

36 

0 

25 

0 

11 

0 

3 

0 

2 

0 

0 

Polymixin 

. 2 

23 

0 

11 

1 

0 

0 

3 

0 

0 

0 

0 

Colistin 

4 

3 

7 

7 

5 

2 

0 

0 

1 

0 

0 

0 

Streptomycin 

2 

35 

6 

18 

3 

8 

0 

3 

0 

2 

0 

0 

Sulfamethizole 

0 

28 

0 

23 

0 

7 

0 

3 

0 

1 

0 

0 

Tetracycline 

9 

28 

12 

13 

4 

7 

0 

3 

0 

2 

0 

0 

Demethylchlortetracycline 

1 

23 

1 

16 

2 

1 

0 

4 

0 

1 

1 

0 

Nalidixic 5 meg . . . . 

18 

18 

21 

5 

3 

5 

0 

4 

0 

1 

1 

0 

30 meg 

26 

10 

23 

3 

6 

2 

3 

1 

0 

1 

1 

0 

60 meg 

32 

4 

23 

3 

7 

1 

3 

1 

0 

1 

1 

0 


culture, one grew Aerobacter, and one Pseudo- 
monas. One failed to improve on nitrofurantoin 
and sulfamethizole; the other to chloramphenicol, 
tetracycline, novobiocin and sulfamethizole. The 
latter did respond to colistin but relapsed when 
the drug was discontinued. Both responded to 
two to four weeks therapy with nalidixic acid. 
The last patient failed to respond to nalidixic 
acid but did revert to normal with chloramphen- 
icol. 

Category 2 comprised three women, two hav- 
ing acute exacerbation of chronic pyelonephritis 
and one recurrent cystitis. Cultures demonstrated 
E. coli in 2 and Pseudomonas in 1. Two were 
treated with tetracycline and sulfamethizole 
during the acute phase without improvement. 
All three had prompt relief and normal uri- 
nalyses when nalidixic acid was administered for 
two to four weeks. No further relapses occurred 
within a twelve month period. 

Category 3 consisted of seven patients, six 
male and one female all with chronic infections 
and obstructions. Three had chronic cystitis, two 
with prostatic hypertrophy and one with urethral 
stricture; and four had chronic pyelonephritis, 
one with a ureteral calculus, one with a renal 
calculus, one with hydronephrosis secondary to 
a retrocaval ureter, and one with bilateral hydro- 
nephrosis secondary to contracture of the bladder 
neck. Surgical correction of the causes of ob- 
struction was done in each patient except the 


one with urethral stricture in whom periodic 
urethral dilatations were performed. After sur- 
gery pyuria persisted in all despite treatment 
with sulfonamides, chloramphenicol, tetracy- 
cline, and nitrofurantoin. Organisms obtained on 
culture were: Pseudomonas 3, E. coli 1, Proteus 
1, Aerobacter 1, and an unidentified Gram neg- 
ative rod 1. Six improved on nalidixic acid five 
still having normal urinalysis three to eight 
months after treatment. The patient with ureth- 
ral stricture had recurrent symptoms and pyuria 
four months later when the stricture was found 
to have recontracted. One patient with bilateral 
hydronephrosis had initial improvement, discon- 
tinued the drug after two weeks, and did not re- 
turn for further follow-up until eleven months 
later. Again E. coli was found but did not re- 
spond to nalidixic acid. 

Category 4 consisted of eight patients, five 
males and three females all with severe chronic 
infections requiring long-term therapy. Two were 
children aged three and six years. Four had 
chronic pyelonephritis (bilateral atrophic pyelo- 
nephritis 1, severe bilateral hydronephrosis sec- 
ondary to congenital vesical neck contracture 1, 
bilateral polycystic kidney disease 1, and mod- 
erate hydronephrosis secondary to uretero-pelvic 
obstruction 1). Four had chronic cystitis (sec- 
ondary to urethral stricture 2, congenital con- 
tracture of the vesical neck 1, post transurethral 
resection 1). Surgical correction of obstruction 


Volume 61 
Number 1 


NALIDIXIC ACID — WARRES 


29 


was performed in all except cases of urethral 
stricture where periodic urethral dilatation was 
performed. Bacteria obtained on culture were: 
Pseudomonas 7, Aerobacter 1. Postoperatively 
all failed to respond to a great variety of anti- 
biotics. All responded to an initial course of 
nalidixic acid. One three year old male with 
hydronephrosis secondary to vesical neck con- 
tracture, was given 1 Gm. nalidixic acid daily 
for six months with resultant normal urinanalyses 
and negative urine cultures since. All others re- 
lapsed when the drug was discontinued after 
four weeks of therapy. All failed to respond to 
various antibiotics again. All responded to an- 
other course of nalidixic acid. When dosage was 
reduced to 0.25 Gm. four times daily in two 
adults, pyuria recurred and persisted despite 
increasing the dosage to two grams daily. One 
of these patients responded to a combination of 
tetracycline and nalidixic acid. In four patients 
nalidixic acid therapy has been maintained for 
up to ten months with control of the pyuria and 
without reaction. Two of these patients have 
moderate elevation of their blood urea nitrogen 
as a result of their diseases. One has had inter- 
mittent nausea and anemia which we attribute 
to renal insufficiency. 

Two patients with cystitis and prostatic hyper- 
trophy complained of nausea when nalidixic 
acid was administered and voluntarily discon- 
tinued the drug after two days. One patient with 
persistent hematuria of one month’s duration, 
negative urine cultures, acid fast and Papanico- 
laou smears, and cystoscopic and pyelographic 
findings was placed on nalidixic acid without im- 
provement. She subsequently was discovered to 
be sensitive to Butazolidin and the hematuria 
ceased when this drug was discontinued. 


No fungus overgrowth, kidney involvement, 
or blood dyscrasia were observed. Toxicity con- 
sisted of nausea in two patients. 

Comment 

Both in vitro and in vivo studies indicate nali- 
dixic acid to be an effective drug in the treatment 
of Gram negative urinary tract infections. Nau- 
sea of moderate degree in two patients was the 
only reaction noted. 

Minimal dosage in adults should be two grams 
in divided doses. Collaborative studies 1 have in- 
dicated that one Gram four times daily for one 
to two weeks is preferable with continued ther- 
apy at two grams daily. Dosage below this may 
result in treatment failures with emergence of 
resistant strains. Children seem to respond to 
one-half of the adult dose. This study again 
emphasizes the importance of relieving urinary 
tract obstruction if one is to eliminate infection. 

Summary 

In vitro sensitivity studies of organisms from 
eighty patients and in vivo clinical trials in 
twenty-six cases utilizing nalidixic acid indicates 
this to be an effective, safe drug in the treatment 
of urinary’' tract infections due to Gram-negative 
organisms. 

1636 South Glenstone 
Springfield, Missouri 

Bibliography 

1. A Summary of Experimental Data in Animals and Human 
Subjects. Win 18,320 (Negram), Brand of Nalidixic Acid. Janu- 
ary 2, 1963. Winthrop Laboratories. New York, N. Y. 

2. Buchbinder, M. ; Webb, N. C. ; Andersen, L. ; and McCabe, 
W. R. : Laboratory Studies and Clinical Pharmacology of Nali- 
dixic Acid (Win 18,320). To be published. 

3. Jameson, R. M., and Swinney, J. : A Clinical Trial of the 
Treatment of Gram-Negative Urinary Infections With Nalidixic 
Acid. Brit. J. Urol. 35 :122-124, June 1963. 


OVARIAN METASTASES 

(Continued from page 26) 

Bibliography 

1. Dunphy, J. E. : Metastatic and Recurrent Carcinoma of 
the Colon and Rectum : Surgical Significance and Management, 
J. Dis. Colon & Rect. 2 :77, 1959. 

2. Economou, S. G., et al : Prophylactic Measures in the 
Spread of Carcinoma of the Colon and Rectum, J. Dis. Colon & 
Rect. 2:98, 1959. 

3. Jackson, B. R. : Carcinoma of the Colon; Avenues of 
Spread and Methods of Preventing Recurrence, J. Dis. Colon & 
Rect. 1 : 186, 1958. 

4. Harkins, Moyer, and Allen, Rhoads: Surgery, Principles 
and Practice. Lippincott, 2nd Ed. 1957. 

5. Gilbertsen, V. A. : Adenocarcinoma of the Large Bowel ; 
1340 Cases With 100 Per Cent Follow-up. Surg. 46:1027, 1959. 

6. Garlock, J. H., et al : Twenty-five Years Experience With 
Surgical Treatment of Cancer of the Colon and Rectum : Analy- 
sis of 1.887 Cases, J. Dis. Colon & Rect. 5 :247, 1962. 

7. Swinton, N. W. : Moszkowski, E., and Snow, J. C. : Cancer 
of the Colon and Rectum ; A Statistical Study of 608 Patients, 
S. Clin. N. A. 39:745 (June) 1959. 

8. Bacon, H. E. : Major Surgery' of the Colon and Rectum: 
Rehabilitation and Survival Rate in 2,457 Patients, J. Dis. Colon 
& Rect. 3 :393, 1960. 


9. Sherman. L. F. ; Tenner, R. J. ; and Chadbourn, W. A.: 
Prophylactic Oophorectomy With Carcinoma of the Rectum and 
Colon, Minnesota Med. 45 :1219, 1962. 

10. Willis, R. A. : The Spread of Tumors in the Human 
Body, J. and A. Churchill, London, 1934. 

11. Burt, C. A. V.: Prophylactic Oophorectomy With Resec- 
tion of the Large Bowel for Cancer, Am. J. Surg. 82 :571. 1951. 

12. Burt, C. A. V. : Carcinoma of the Ovaries Secondary to 
Cancer of the Colon and Rectum, J. Dis. Colon & Rect. 3 :352, 
1960. 

13. Wheelock, M. C., and Putong, P. : Ovarian Metastases 
From Adenocarcinoma of the Colon and Rectum, Obst. & Gynec. 
14:291, 1959. 

14. Abrams, R. A. ; Spiro, R., and Golstein, N. : Metastasis in 
Cancer, Cancer 3 :74, 1950. 

15. Deddish, M. R., and Stearns, M. : Surgical Procedures for 
Carcinoma of the Left Colon and Rectum. With Five Year End 
Results Following Abdomino-Pelvic Dissection of Lvmph Nodes, 
Am. J. Surg. 99:188, 1960. 

16. Rendleman, D. F.. and Gilchrist, R. K. : Indications for 
Oophorectomy in Carcinoma of the Gastro-intestinal Tract, 
Surg., Gynec. & Obst. 109:364, 1959. 

17. Offen, J. A., and Saltzstein. H. C. : The Diagnostic Con- 
fusion of Ovarian Carcinoma With Carcinoma of the Colon, 
Am. J. Obst. & Gynec. 72 :1120. 1956. 

18. Woodruff, J. D.. and Novak. E. R. : The Krukenberg Tu- 
mor. Obst. & Gynec. 15:351, I960. 

19. Johansson, H. : Clinical Aspects of Metastatic Ovarian 
Cancer of Extragenital Origin. Acta Obst. et Gynec. Scandinav. 
39:681. 1960. 


Statement of Opposition of the 
Missouri State Medical Association 

To: H.R. 3920 , The King-Anderson Bill 


Special Article 

On behalf of the nearly 4,000 physician mem- 
bers of the Missouri State Medical Association, 
we are submitting to your committee a report 
concerning several important elements relating 
to the availability of health care assistance for 
the aged in the State of Missouri. We believe 
that these facts will be of value to the committee 
in its consideration of proposed legislation to 
establish a federal health care program through 
the social security system. 

In June 1961, at the close of the 71st session 
of the Missouri General Assembly, a resolution 
was passed establishing a joint committee of the 
Assembly for the purpose of making a complete 
and thorough study of the problem of providing 
health care assistance to the senior citizens of 
Missouri and reporting its findings and recom- 
mendations to the session of the legislature con- 
vening in January 1963. 

This interim committee, composed of state 
senators and representatives of both political 
parties, held numerous meetings and public 
hearings throughout the state during an 18 
month period, inviting all interested citizens, and 
professional, business and labor groups to give 
both factual information and suggestions con- 
cerning health care for Missouri’s elderly. 

The Situation in Missouri 

The findings of this committee as reported to 
the general assembly early this year included the 
following: 

“In this nation, the State of Missouri ranks 
second only to the State of Iowa in the proportion 
of persons 65 years of age and over in relation- 
ship to the total population of the state. The 
1960 census showed that more than half a mil- 
lion Missourians (503,411) are aged 65 or over, 
representing 11.7 per cent of the total population 
of this state. Expressed another way, about one 
out of every eight persons in Missouri is 65 years 
of age or older. It has been estimated by sources 
considered reliable that by 1970, Missouri will 


The statement was presented by Dur- 
ward G. Hall, M.D., member of Congress 
from the 7th Missouri District, before the 
House Ways and Means Committee in 
Washington, D. C., on November 20, 1963, 
as part of his testimony in opposition to 
H.R. 3920, the King-Anderson bill. 


have 600,000 persons 65 years of age and over. 
In many rural counties where living is less costly 
and, therefore, a good retirement climate exists, 
the percentage of the total population of the 
counties of persons 65 or older approaches and 
even exceeds 20 per cent. 

“Today about six out of every 10 aged persons 
eligible for retirement (58.7 per cent) in Mis- 
souri receive payments under the Federal Social 
Security program. The actual number of per- 
sons receiving these benefits is 295,000 and the 
average monthly payment is $71.50. At present, 
about one fourth of all aged persons in Missouri, 
about 108,000, are receiving State Old Age As- 
sistance payments, popularly referred to as the 
‘Old Age Pension.’ At the present time about 39,- 
000 aged persons are receiving both payments 
from the Federal Government under Social Se- 
curity and the ‘State Old Age Pension’ primarily 
because they happen to have high medical ex- 
penses which cannot be met from the benefits 
received from one program alone and they do, 
therefore, qualify for both programs. 

“It is most interesting to note that the Missouri 
Division of Employment Security in November 
1959, estimated that about 103,000 persons 65 and 
over in Missouri had some employment. This 
indicates that about one out of five aged persons 
are either employed for wages or self-employed 
on a part time or full basis. . . . 

“The Committee does not mean to infer that 
all Senior Citizens in this state are in dire need 
of medical assistance. This is not the case. For- 




30 


Volume 61 
Number 1 


STATEMENT OF OPPOSITION OF THE MSMA 


31 


tunately, as noted by the number employed, 
many are in very good health and have few, if 
any, medical expenses. Many others, though not 
employed, are able to get along quite well 
through savings and Federal Social Security 7 pay- 
ments. Many have been able to provide them- 
selves with insurance to help in their medical 
emergencies. Many are being assisted privately 7 
by families who are able and willing to assist 
their parents in medical emergencies. Many local 
government units are presently 7 doing what their 
financial abilities will allow to assist Senior Citi- 
zens with their medical care problems. The 
Counties of Buchanan, Greene, Marion and Pet- 
tis have unique and admirable local programs of 
medical care in effect. Also the two metropolitan 
counties of Jackson and St. Louis and the City 7 
of St. Louis and Kansas City offer considerable 
assistance. The Committee has viewed with 
pleasure the apparent growth of feeling of local 
responsibility 7 and the growth of the use of pri- 
vate medical insurance by those Senior Citizens 
who can afford it. 

“. . . It is the conclusion of the committee that 
the greatest need of all (for health care assist- 
ance) is found within that group who are pres- 
ently 7 on the Old Age Assistance rolls of the 
State of Missouri. Most of this group of persons 
do not have the type of employment history 7 that 
also allows them to draw 7 payments under the 
Federal Social Security 7 program. They 7 , by 7 
statute, are extremely limited in their income 
and available assets or they 7 wouldn’t and couldn’t 
be on the OAA rolls for state payment. The max- 
imum monthly payment to this group is presently 7 
$70.00 and the average payment is approximately 
$65.00 monthly. It is obvious that after present 
day living expenses are taken from such an 
amount that there is and could be little, if any 7 - 
thing, left for medical expenses no matter how 7 
dire the need might be. The Committee does 
not mean to infer that there is no need for medi- 
cal assistance in any group other than the Old 
Age Assistance group.” 

Legislative Action in 1963 

The interim committee’s recommendations for 
legislative action became the basis of bills passed 
by the Missouri General Assembly 7 of this year, 
further implementing the Kerr-Mills Law in 
Missouri. 

The Missouri State Medical Association fa- 
vored and worked for the passage of this legisla- 
tion. It was the result of an intensive year-and- 


a-half long study 7 of the problem by 7 10 state 
legislators, and presented a program tailor-made 
to the needs of Missouri’s elderly. 

The first of the two programs, which has been 
signed into law by 7 the Governor, provides in- 
creased aid for health and hospital expenses for 
persons receiving Old Age Assistance. The sec- 
ond bill, while passed by both houses of the 
General Assembly, was vetoed by 7 the Governor 
after the close of the session. It would have 
established a program of health care assistance 
for the “near-needy 7 ” aged persons who are not 
eligible for OAA, who have adequate financial 
resources for normal expenses, but whose income 
and resources are insufficient to meet the costs 
of serious or prolonged illness. According to 
published reports, the Governor’s veto was based 
principally 7 on the uncertainty 7 of the cost of the 
program rather than its desirability or expense. 
He was quoted as saying, “I feel that in the fu- 
ture if it is possible to get accurate information 
as to how 7 much such a program will cost, then 
it should be given consideration.” 

Recipients of public assistance are now pro- 
vided benefits for inpatient hospital care for 
serious illness or injury for which outpatient care 
will not suffice; the condition need not be, as 
formerly 7 , a “medical emergency” or an “acute 
serious illness.” Monthly 7 payments to those re- 
quiring care in a nursing home have been raised 
to a maximum of $80, and payments to complete- 
ly 7 bedfast and totally 7 disabled welfare recipients 
have been raised to a maximum of $110 a month. 
For the first time, Missouri will provide bene- 
fits for dental expenses, drugs and medicines— 
the dental care to be authorized by 7 the division 
of welfare and provided by a licensed dentist, 
and drugs and medicine also to be authorized by 
the Division of Welfare and prescribed by 7 a li- 
censed physician, osteopath or dentist. The legis- 
lature authorized $4,322,320 in state funds to 
implement this program for the 1963-1965 bi- 
ennium. Under Kerr-Mills provisions, this will 
be matched, we are informed, by 7 about $6,000,- 
000 in Federal funds. 

Under the provisions of the proposed program 
for the near-needy 7 , aid would have been pro- 
vided for inpatient hospital care for serious ill- 
ness or injury, as well as for drugs prescribed by 
the attending physician for a period of up to 30 
day 7 s after the patient’s release from a hospital. 

We are gratified that this program had the 
support of the state legislature and believe that 
a similar bill will be introduced and passed in 
the next session of the General Assembly. 


32 


STATEMENT OF OPPOSITION OF THE MSMA 


Missouri Medicine 
January, 1964 


Private Insurance 

In the private realm, the non-profit Blue Shield 
and Blue Cross Plans of St. Louis and Kansas 
City recently introduced special medical surgical 
and hospital protection plans for persons aged 
65 and over to supplement the coverage they 
have long offered Missouri citizens without re- 
gard to age. 

The St. Louis and Kansas City Blue Shield pro- 
grams for persons over 65 are modeled on the 
program developed jointly by the American Med- 
ical Association and the National Association of 
Blue Shield Plans. Both programs include paid- 
in-full benefits for members with limited in- 
comes, and, as of June 30, a total of 9,000 per- 
sons were enrolled in the two Senior Citizen Pro- 
grams. Including these special “senior" programs, 
a total of more than 75,000 Missourians aged 65 
and over are now enrolled in various non-group 
medical-surgical protection plans of the two 
Blue Shield Plans. 

Many thousands of Missouri’s over-65 group 
are similarly enrolled in Blue Cross hospitaliza- 
tion programs, while still more thousands are 
covered by commercial insurance. 

Conclusion 

As physicians, the members of the Missouri 
State Medical Association are deeply concerned 
with the problem of medical care for the aged. 
As a group, and individually, we worked for the 
passage of the two statutes detailed. 

The Kerr-Mills program helps those elderly 
persons who really need assistance. We believe 
that this is documented by the close relationship 
between the findings of the interim committee 
of the state legislature and the statutes that body 
passed. The Missouri Assembly found out what 
kind of medical care program was needed— and 
promptly enacted it! 

Statistics compiled recently by the Missouri 
Division of Health in cooperation with the Mis- 
souri Hospital Association concerning the meth- 
ods of payment by patients discharged from a 
random hospital sample, made up of 63 outstate 
Missouri institutions, between July 1962 and 
December 1962, indicate that the problems of 
the aged in obtaining and paying for hospital 
care have been greatly exaggerated. 

The figures from this six-months period show 
that, of a total of 90,192 persons discharged from 
care in these hospitals, only 929— or 1 per cent 
—were unable to pay any of their costs. Of this 
number, just 186— two-tenths of 1 per cent of 
the over-all total— were age 65 or over. 

During this same period, Missouri’s program 


of health care for the needy aged— an implemen- 
tation of the Kerr-Mills Act— provided care for 
2,122 patients over age 65 out of the 90,192 total 
cases documented in the study. In addition, 416 
persons aged 65 or over received some assistance 
in paying hospital costs from this state program 
to supplement resources of their own. 

The striking fact is, then, that the remainder 
of the more than 90,000 cases in this study were 
able to pay for their own care through Blue 
Cross, insurance benefits, credit payments or 
cash resources. Only 2,724 people over age 65, 
out of more than 90,000 patients, needed assist- 
ance through the Kerr-Mills program or direct 
charity from the hospitals. This is only a little 
more than 3 per cent. 

These statistics point up the fact that the need 
for governmental aid is minor. Even at the 1962 
level of benefits, Missouri’s Kerr-Mills program 
was taking care of almost the entire problem that 
does exist. Since this study was made, of course, 
the Missouri legislature has authorized the in- 
creased and expanded payments under the Kerr- 
Mills program which have been discussed earlier. 
It is apparent that what problem there is in pro- 
viding medical care for the aged in Missouri is 
being taken care of by the state, and that, there- 
fore, there is no need for the enormously costly 
and restrictive King-Anderson approach. 

Further, we believe that it is important to 
note the increasing number of persons aged 65 
or over who are being covered by private health 
insurance plans. Nationally, 53 per cent of the 
elderly not in institutions had such protection at 
the close of 1961— an increase of 132 per cent 
over a 10-year period! 

Finally, we are convinced that the adoption 
of a compulsory, federal health care plan for the 
aged under the social security system would dis- 
rupt the traditional doctor-patient relationship, 
and, thereby, lead to a deterioration of the sys- 
tem of health care which is second to none in 
the world. Not only would such a program inter- 
fere with patient care, it would force the work- 
ing people of today to pay higher taxes to pro- 
vide such care to every man and woman over a 
certain age limit, regardless of need. 

Let me emphasize again that our Association 
believes that medical care should be provided 
for those persons who are in need. And this, we 
believe, can be done at the local and state levels 
—as it is now being done in Missouri— without the 
adoption of a federally-controlled, compulsory 
scheme. 

We strongly urge, therefore, that the members 
of the Ways and Means Committee, vote against 
and reject H.B. 3920, the “King-Anderson” bill. 




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33 


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The recommended initial adult dosage is two tablets (2.5 mg. each) 
three or four times daily, reduced to meet the requirements of each 
patient as soon as the diarrhea is controlled. Maintenance dosage may 
be as low as two tablets daily. Children’s daily dosage (in divided doses) 
varies from 3 mg. for a child of 3 to 6 months to 10 mg. for one 8 to 
12 years of age. Lomotil is an exempt narcotic; its abuse liability is 
low and comparable to that of codeine. Recommended dosages should 
not be exceeded. Side effects are relatively uncommon but among those 
reported are gastrointestinal irritation, sedation, dizziness, cutaneous 
manifestations, restlessness and insomnia. Lomotil should be used with 
caution in patients with impaired liver function and in patients taking 
addicting drugs or barbiturates. Lomotil is a brand of diphenoxylate 
hydrochloride with atropine sulfate; the subtherapeutic amount of 
atropine is added to discourage deliberate overdosage. 

Research in the Service of Medicine 


SEARLE 




Kenneth C. Hollweg, M.D. 


President’s 

Message 


The 106th Annual Session of the Missouri State 
Medical Association will be held in St. Louis in only 
two months— March 8 to 11— and it is certainly not 
too early to make plans to attend what promises to 
be an outstanding meeting. 

All who have attended recent Annual Sessions 
know of the excellence of the scientific programs. 
Dr. Matthews and his committee have arranged an 
exceptional group of presentations again this year— 
a program from which any practicing physician can 
benefit greatly. 

In addition, I know I need not emphasize the im- 
portance of the deliberations of the House of Dele- 
gates in preparation for the critical months ahead. 
This year, I hope that everyone will take renewed 
interest in the Association’s policies and make the 
effort to attend the meetings of the House and the 
Reference committees. As you know, every MSMA 
member is welcome to present his views on the 
topics being considered by the Reference Commit- 
tees. 

You will find the preliminary program of the ses- 
sion in this issue of Missouri Medicine. I urge you 
to mark this event as a “must” on your 1964 calen- 
dar today. 



34 



EDITORIAL 


AMA ISSUES OPTIMISTIC REPORT 
ON MEDICAL EDUCATION 

The American Medical Association on Nov. 
15, 1963 reported significant advances in three 
areas of medical education vital to the future 
quality of medical service in this country. 

The 1962-63 annual report on medical educa- 
tion, prepared by the AMA Council on Medical 
Education and Hospitals, cited the following de- 
velopments : 

—Firm commitments for the construction of 
six new medical schools, bringing to 11 the total 
number now in the planning stage. 

—A 10 per cent increase in the number of med- 
ical school applicants, the first upturn in six 
years. 

—Evidence of an enlarging pool of potential 
medical teachers. 

A major concern of recent years has been the 
adequacy of the future supply of physicians for 
a growing population with increasing expecta- 
tion for medical service, the council said. An in- 
crease in the future supply of physicians is a 
well-documented necessity and this depends 
primarily on expansion of facilities and an in- 
crease in medical teachers and students, it said. 

“Though it is too early for certainty, still, on 
the basis of current progress, cautious optimism 
can be expressed in regard to satisfying future 
needs,” the council said. 

Despite the generally optimistic report, the 
council said efforts to interest more students in 
a medical career, which have been intensified in 
recent years, should not be relaxed. Medicine 
will continue to compete with an increased num- 
ber of other “status professions” for top students, 
it said. 

The public announcement of six new medical 
schools was made by the University of Arizona, 
Tucson; Mt. Sinai Hospital, New York City; Uni- 
versity of Massachusetts, Amherst; University of 
California, San Diego; Michigan State Univer- 
sity, East Lansing, and Pennsylvania State Uni- 
versity, University Park, the AMA report said. 

Of the five new schools previously announced, 
New Mexico plans to enroll its first medical stu- 
dents for the 1964-65 academic year; Rutgers 
plans to accept an entering class for 1965-66, 
and the University of Texas, San Antonio, for 
1966-67. Brown has accepted for 1963-64 its first 
college class which will in part constitute its first 
medical students in the next few years, and the 


University of Connecticut is in the process of 
developing its architectural and academic plans. 

There are many other institutions which are 
giving serious study to the establishment of medi- 
cal schools, the report said, and a growing em- 
phasis on construction of teaching facilities is 
anticipated as a result of the Health Professions 
Educational Assistance Act passed by Congress 
this year. 

The act for the first time authorizes federal 
matching grants for construction of teaching fa- 
cilities. Such matching funds have long been 
available for construction of research facilities, 
the report noted, and there has been an appar- 
ent disproportionate expenditure of construction 
funds for research as opposed to teaching fa- 
cilities. 

The increase in the number of students apply- 
ing for admission to medical schools confirmed 
the council’s prediction a year ago that a declin- 
ing trend since 1949 reached its lowest point in 

1961- 62 and would begin an upward swing. 

Applicants for medical schools in 1962-63 

totaled 15,847, compared with 14,381 in the pre- 
vious year, an increase of 1,466 or 10 per cent. 

Preliminary estimates indicate that the num- 
ber of applicants for the current 1963-64 class 
have again increased at least 15 per cent to 18,- 
184, the report said, and it appears likely that 
the number will increase substantially during 
the next several years. 

Total enrollment in the nation’s 87 approved 
medical schools for 1962-63 was 31,491, up 413 
from 1961-62, the report said. However, it said, 
a more satisfactory estimate of the rate of ex- 
pansion of teaching facilities may be the addi- 
tion of 159 first-year students during that year, a 
2.2 per cent increase. 

However, the council concluded that the pres- 
ent supply of full-time faculty was adequate or 
nearly so. This was based on the over-all con- 
tinuing decline in the ratio of teachers to stu- 
dents and the fact that the difference in this 
ratio among schools in good financial condition 
and the less affluent institutions has decreased, 
it said. The ratio among the affluent schools for 

1962- 63 was 4.5:1, compared with 6.7:1 among 
the other schools, it was reported. 

As to the future, the council said, if the same 
rate of increase in full-time faculty recorded in 
the past three years continued until 1970, the 
total number would then be somewhat in excess 
of the estimated demand. 


35 




Ramblings of the Field Secretary 


Dr. Leslie of Kirkwood and Dr. Senn of Herculaneum 
register. 

The Fourth Annual M.D. Day was held at the 
University of Missouri School of Medicine, Fri- 
day and Saturday, November 15 and 16. Actual- 
ly, this represented the Fourth Annual “get to- 
gether” of the medical alumni and other medical 
friends and the faculty of the school of medicine. 
The scientific part of the program was presented 
as a joint effort by the Oklahoma University and 
Missouri University Medical School faculties. In 


Drs. Dowell, Siegel, Whitten and Schulte consider an 
important matter. 

addition to the scientific program held through- 
out the day on Friday and on Saturday morning, 
a Friday evening social hour and dinner was held 
at the Daniel Boone Hotel and a buffet luncheon 
was served at the Medical Center Saturday noon. 

Approximately 200 physicians registered for 
this outstanding occasion. All sessions, beginning 
with the first on Friday morning at 9:00 a.m., 
were well attended. During coffee breaks and 
regular off periods, it was interesting to see old 


friends greeting each other. In numerous in- 
stances some physicians, who were classmates, 
met again for the first time. Added to the oppor- 
tunity of participating in an excellent scientific 
program, the privilege of visiting with friends 
from all over the state, attending the MU-KU 
freshman football game and the Oklahoma-Mis- 
souri game, those attending this year’s M.D. Day 
had a full and memorable weekend. 


Drs. Knight of Kansas City and Smith of Clinton 
shake hands with audience approval. 

The attendance and apparent interest in this 
year’s M.D. Day affair is indicative of the mo- 
mentum which this idea has now gathered. This 
year’s attendance was the largest to date and the 
many comments overheard point to a continuing 
increase in interest and participation in future 
M.D. Day programs to be held at the University 
of Missouri School of Medicine to coincide each 
year with an outstanding football game at the 
university. 


Dr. Hamlin, President M.U. Medical Alumni, presides 
at banquet. 


38 





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7 1423 



News — Personal and Professional 


The chairman of scientific exhibits at the re- 
cent annual meeting of the American Society of 
Anesthesiology, held in Chicago, was Oral B. 
Crawford, M.D., Springfield. 


“Emergency First Aid” is the title of a book 
written by Fred A. Wappel, athletic trainer at 
Missouri University. It is being edited by Hugh 
Stephenson, M.D., Columbia. 


The VFW Auxiliary recently held a meeting 
at which a film on cancer was shown and dis- 
cussed by T. J. Fisher, M.D., of Hannibal. 


A memorial plaque honoring the late H. B. 
Henrickson, M.D., was unveiled at a ceremony 
in Poplar Bluff on November 12, 1963. 


The speaker at the November meeting of the 
Jasper County Medical Society was Frank Mc- 
Dowell, M.D., of St. Louis. 


The St. Louis Pediatric Society has installed 
James K. Turner, M.D., St. Louis, as president 
for the 1963-1964 term. Other officers elected 
were Francis X. Lieb, M.D., president-elect and 
Helen M. Aff-Drum, M.D., secretary-treasurer. 


At the fourth Annual Dinner of the medical 
staff of St. Vincent’s Hospital, portraits and 
plaques were presented to S. R. Banet, M.D., and 
Rev. Joseph E. McIntyre, C.M., by Sister Juli- 
ana, Administrator of the hospital. 



Dr. Banet and Rev. McIntyre receive plaques from 
Sister Juliana. 


The Catholic Hospital Association recently an- 
nounced that Patrick H. Hoey, M.D., formerly 
on the staff of the Air Force Medical Services, 
was appointed director of medical relations. 


The Jackson County Medical Society held a 
Recognition Dinner on November 20 for Mr. 
William H. Bartleson on the occasion of twenty- 
five years as an executive official with the society. 


The medical examiner system for Missouri in 
lieu of the office of coroner was proposed by 
Charles B. Wheeler Jr., M.D., Kansas City, at 
the recent joint annual meeting of the St. Joseph 
Bar Association and the Buchanan County Med- 
ical Society. 


“Advances in Surgery” was the subject dis- 
cussed by Charles Willman, M.D., St. Joseph, at 
a recent meeting of the Kiwanis Club in St. Jo- 
seph. 


“Advances in the Treatment of Cancer” was 
discussed by Herbert L. Warres, M.D., Spring- 
field, at a meeting of the Springfield Community 
Planning Council. 


Selected for the rank of Knight Commander 
of the Court of Honor recently was Armand D. 
Fries, M.D., St. Louis, one of 44 Thirty Second 
Degree Masons so selected. 


DEATHS 

Morris, Clyde S., M.D., Caruthersville, a grad- 
uate of Tulane University, 1916; member of Pem- 
iscot County Medical Society; aged 73; died Oc- 
tober 8, 1963. 

Kohn, Cecil M., M.D., Kansas City, a graduate 
of the University of Kansas, 1932; member of 
Jackson County Medical Society; aged 56; died 
November 7, 1963. 

Haynes, Lee, M.D., Kansas City, a graduate of 
Beaumont Hospital Medical College, 1900; mem- 
ber of Jackson County Medical Society; aged 90; 
died November 8, 1963. 

Shutt, Cleveland S., M.D., St. Louis, a grad- 
uate of St. Louis College of Physicians and Sur- 
geons, 1904; member of St. Louis Medical So- 
ciety; aged 82; died November 26, 1963. 


38 


ADVERTISEMENTS 


39 


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3. Hazard, R. and Savini, E. Gand., 92:471, 1963. 

4. Dorsey. J. L.: Ann. Int. Med., 10:628, 1936; 5. Ras- 
mussen, K. B.: Ugeskr.laeger, 118:222, 1956: 6. Ejrup, 
B.: Sven. lak. Tid., 53:2634, 1956; 7. Jochum. K. and 
Jost, F.: Munch, med. Wchnschr., 103:618. 1961; 8. 
Jost, F. and Jochum, K.: Med. Klin., 54:1049, 1959; 
9. Smoking and Health. Summary and Report of the 
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MISSOURI STATE MEDICAL ASSOCIATION 


Preliminary Program 
106 th Annual Session 
Hotel Chase, St. Louis 
March 8, 9, 10, 11, 1964 
Sunday, March 8, 1964 


12:00 noon Registration of Delegates. Lobby floor. 

1:30 p.m. House of Delegates. 

3:00 p.m. Reference Committee meetings. 

6:30 p.m. Cocktails and buffet dinner honoring Leonard T. Furlow, M. D., 
and Mrs. Delevan Calkins. St. Louis Medical Society Build- 
ing, 3839 Lindell Blvd. Complimentary by the St. Louis 
Medical Society. 


Monday, March 9, 1964 

8:00 a.m. Registration. Lobby floor. 

9:00 a.m. Panel: What’s New. 

Moderator: Thomas F. Frawley, M.D., St. Louis. 

New Trends in Medicine: William D. Davis Jr., M.D., New 
Orleans. 

New Trends in Surgery: Thomas L. Marchioro, M.D., Denver. 
New Trends in Allergy: Charles W. Parker, M.D., St. Louis. 

New Trends in ENT: John J. Shea, M.D., Memphis, Tenn. 

10:30 a.m. Intermission to View Exhibits. 

11:00 a.m. Panel: Current Concepts in Treatment of Chronic Renal Disease. 
Moderator: C. Thorpe Ray, M.D., Columbia. 

Problems Involved in an Artificial Kidney Center Devoted Solely 
to Chronic Dialysis, F. K. Curtis, M.D., Seattle. 

Some Problems Involved in Human Homo-transplantation, Thomas 
L. Marchioro, M.D., Denver. 

12:00 noon. 50 Year Club Luncheon. 

12:00 noon. Committee on Maternal Welfare Luncheon. 

Speaker: Arthur L. Haskins, M.D., Baltimore, Md. 

Medical Session. 

2:00 p.m. Panel: Liver Disease. 

Moderator: Robert E. Koch, M.D., St. Louis. 

Problems in Treatment of Cirrhosis, William D. Davis Jr., M.D., 
New Orleans. 

Sponsored by the Missouri Society of Internal Medicine. 
Hemochromatosis, Speaker to be announced. 

Sponsored by the Missouri Diabetes Society. 

Current Problems in Hepatitis, Speaker to be announced. 

Surgical Session. 

2:00 p.m. Regional Enteritis — Surgical Aspects, B. Marden Black, M.D., 
Rochester, Minn. 

Sponsored by the Missouri Surgical Society. 

2:30 p.m. Subject to be announced. Arthur L. Haskins, M.D., Baltimore, Md. 
Sponsored by the St. Louis Gynecologic Society. 

40 


Volume 61 
Number 1 


ORGANIZATION ACTIVITIES 


41 


3:00 p.m. To be announced. 

Sponsored by MSMA Committee on Trauma. 

3:30 p.m. Intermission to View Exhibits. 

4:00 p.m. House of Delegates. 

5:30 p.m. Reference Committee meetings. 


Tuesday, March 10, 1964 
8:00 a.m. Registration. Lobby floor. 

9:00 a.m. Panel: Hits and Misses in Current Drug Therapy. 

Moderator: Edward D. Kinsella, M.D., St. Louis. 

Cancer Chemotherapy, C. Gordon Zubrod, M.D., Bethesda, Md. 
The Use of Thyroid, Thyroxine and Triido-thyronine in the Treat- 
ment of Hypothyroidism and Other Conditions, Paul H. 
Lavietes, M.D., New Haven, Conn. 

MAO Inhibitors, Their Use, Misuse and Therapeutic Effects, 
Nathan S. Kline, M.D., Orangeburg, N. Y. 

9:00 a.m. Panel: Adolescent Medicine. 

Moderator, James P. King, M.D. 

Panelists: 

Felix P. Heald Jr., M.D., Washington, D. C. 

Willard M. Allen, M.D., St. Louis. 

Robert J. Corday, M.D., St. Louis. 

10:30 a.m. Intermission to View Exhibits. 

11:00 a.m. Subject to be announced, M. D. Overholser, M.D., Columbia. 
Missouri University Medical Award Winner. 

11:30 a.m. To be announced. 

12:00 noon. University of Missouri Medical Alumni Association Luncheon. 

1:30 p.m. Medical Economics Session. 

Topic to be announced. 

3:00 p.m. Intermission to View Exhibits. 

3:30 p.m. Panel: Treatment of Hiatus Hernia and Esophagitis. 

Moderator: Hector W. Benoit Jr., M.D., Kansas City. 

Panelists : 

Donald B. Effler, M.D., Cleveland, Ohio. 

Nicholas C. Hightower, M.D., Temple, Tex. 

Richard Schatzki, M.D., Boston, Mass. 

3:30 p.m. Panel: Long Term Management of Ischemic Heart Disease. 
Moderator: To be announced. 

Coronary Arteriography: Clinical and Psychological Correlations, 
Richard S. Ross, M.D., Baltimore, Md. 

Impending Myocardial Infarction, R. E. Beamish, M.D., Winnipeg, 
Canada. 

Prophylactic Anticoagulent Therapy After Myocardial Infarction, 
Herbert E. Griswold Jr., M.D., Portland, Oregon. 

Sponsored by the Missouri Heart Association. 

7:30 p.m. Banquet in Honor of Past Presidents. 


Wednesday, March 11, 1964 


7:30 a.m. House of Delegates Breakfast Meeting. 


THE MISSOURI SOCIETY OF MEDICAL TECHNOLOGISTS 

March 8-11, 1964 

Llotels Chase-Park Plaza, St. Louis 

March 8 

St. Louis University Hospitals — Firmin Desloge Hospital. 

Afternoon — Business meeting — Missouri Society of Medical Technologists. 
Evening — Business Meeting — Missouri Association of Blood Banks. 

March 9 

Stockholm Room — Hotel Park Plaza. 

Morning — Missouri Association of Blood Banks 
Many aspects of Modern Blood Banking are to be presented. 

A question-answer panel will be included in program. 

Afternoon 

Hematology and Coagulation subjects are tentatively scheduled. 

March 10 
Morning 

Bacteriology and related topics are presently planned. 

Afternoon 

Administrative and Personnel problems relating to Laboratories, and Medico- 
legal aspects of Laboratories and Blood Banks will be discussed. 

March 11 
Morning 

Chemistry Program includes quality control, Enzymology and new concepts in 
this field. 


“THE PHYSIOLOGICAL BASIS FOR BIAGNRSIS 
ANB TREATMENT OF HISEASE” 

A One-Day Postgraduate Course Co-Sponsored by 
St. Louis University School of Medicine 
and 

Missouri State Medical Association 
All Sessions at 

St. Louis University School of Medicine 
Wednesday, March 11, 1964 
10:00 a.m. to 3:30 p.m. 

Registration Fee — $10.00, includes lunch 

Send Inquiries to: W. A. Knight Jr., M.D. 

Department of Internal Medicine 
St. Louis University School of Medicine 
1325 South Grand Blvd. 

St. Louis 4, Missouri 

Watch for further announcements 


42 


County Society News 

FIRST DISTRICT 

JOSEPH L. FISHER, ST. JOSEPH, COUNCILOR 
Grand River Medical Society 

On November 14, 1963 thirty-nine members, 
wives, and guests met at Chillicothe’s Strand 
Hotel for dinner and the regular monthly meet- 
ing. 

Dr. Bernie Andrews, of Kansas City gave a 
concise but informative discussion on AMPAC 
and its importance to all of us. 

Dr. David R. Ginder, of the Department of 
Medicine of the University 7 of Missouri, spoke 
on the clinical application of antibiotics. His ex- 
cellent summaries were very well received. 

In addition to Dr. Ginder and Dr. Andrews, 
our guests included Mrs. Andrews, Mrs. Law- 
rence Crispell, President of the State Woman’s 
Auxiliary; Jerry Stretz of Upjohn; and Alan Klein 
of Merck, Sharp and Dohme. 

Jack L. Vinyard, M.D., Secretary 


SECOND DISTRICT 

HARRY L. GREENE, HANNIBAL, COUNCILOR 

Chariton-Macox-Monroe-Randolph 
County Medical Society 

The Chariton-Macon-Monroe-Randolph Coun- 
ty Medical Society 7 held a regular monthly din- 
ner meeting at the Woodland Hospital in Mober- 
ly on Thursday night, November 14. The scien- 
tific speaker for the evening was Harry G. Moore 
Jr., M.D., Medical Director of the Child Center 
of our Lady of Grace in Normandy, Missouri. 
Dr. Moore centered his talk on “The Disturbed 
Child.” He indicated that there are some one 
million children in school in the U. S. who need 
psychiatric care and possibly another million not 
in school needing such care. The percentage of 
disturbed children from broken homes or from 
homes where there is not proper correction is 
much higher, he said. His feeling was that a 
spanking possibly given at the correct time was 
an efficient corrective measure in many cases. He 
pointed out that in some cases in handling dis- 
turbed children, the parents are the major prob- 
lem. 

Officers of the society 7 who were elected to 
serve for 1964 are as follows: President, Thomas 
S. Fleming; Vice-President, L. E. Huber; Secre- 


tary-Treasurer, J. Will Fleming Jr. Delegates to 
State Convention are: Chariton County, F. L. 
Harms, alternate, D. D. Stuart; Macon County, 
James E. Campbell, alternate, Howard Miller; 
Monroe County, F. A. Barnett, alternate, G. M. 
Ragsdale; Randolph County, A. P. Rowlette, al- 
ternate, Robert Hasson. Censors are: Chariton 
County 7 , D. D. Stuart; Macon County, D. E. Eg- 
gleston; Monroe County, F. A. Barnett; Ran- 
dolph County, L. E. Huber. 

In addition to the annual election during the 
business part of the meeting, the society voted 
approval of a four county wide Sabin Oral Polio 
Clinic to be held sometime in the next few 
months. Approval was also given to a program 
of teaching a class of individuals in the area, who 
have dealings with emergency cases, on how to 
give external cardiac massage, artificial respira- 
tion and the proper method of administering 
oxygen. 

Members present at the meeting were: Drs. 
D. E. Eggleston, Howard Miller, Gretchen Col- 
lins, J. E. Campbell and Carl Rinker, all of 
Macon County; F. L. Harms, D. D. Stuart and 
G. C. Rice, Chariton County; F. A. Barnett, Mon- 
roe County; and Josephine Baker, A. P. Rowlette, 
J. Will Fleming Jr., Thomas S. Fleming, R. H. 
Young, W. D. Chute, C. C. Cohrs, L. E. Huber, 
Robert Hasson, P. V. Dreyer, C. C. Smith and 
S. R. Szymanski, all of Randolph County. 

J. W. Fleming, M.D., Secretary 

Marion-Ralls-Shelby County Medical Society 

A dinner meeting of the Marion-Ralls-Shelby 
County Medical Society was held at the Moose 
Lodge in Hannibal on Tuesday night, November 



The speaker catches the attention of all present. 


45 



46 


ORGANIZATION ACTIVITIES 


Missouri Medic nk 
January, 1964 



Drs. Landau, Walterscheid and Foreman confer at 
close of meeting. 


19. Following a social hour and dinner the so- 
ciety took up a number of business matters in- 
cluding discussion of the third Sabin Oral Polio 
Clinic to be held for the Hannibal area on De- 
cember 8. In addition, the new program for dis- 
pensing of drugs under the Kerr-Mills Law in 
Missouri was discussing with a number of phar- 
macists from the Hannibal area, who were pres- 
ent, taking part in the discussion. 

The society feels that definite changes need to 
be made by the Missouri Division of Welfare in 
this particular program. 

Mr. Ray McIntyre, Field Secretary of the 
State Medical Association, was invited to speak 
to the group on State Association matters. His 
remarks were primarily centered on the medical 
student loan program which the State Medical 
Association established in the fall of 1960 and 
which to date has loaned approximately $104,000 
to Missouri residents attending medical schools. 

The scientific discussion of the evening was 
given by Dr. Dan Landau of Hannibal who 
spoke on “Rheumatic Fever.” Dr. Landau is Vice- 
President of the Missouri Heart Association and 
Chairman of the State Wide Advisory Commit- 
tee on Rheumatic Fever to the Missouri Heart 
Association. A question and answer period fol- 
lowed Dr. Landau’s formal presentation. 

John Walterscheid, M.D., Secretary 


FOURTH DISTRICT 

PAUL R. WHITENER, ST. LOUIS, COUNCILOR 

Lincoln-St. Charles County Medical Society 

A dinner meeting of the Lincoln-St. Charles 
County Medical Society was held at the Golf 
View Inn at the St. Charles Golf Course on Tues- 


day evening, November 26. The evening festivi- 
ties began with a social hour followed by din- 
ner and an interesting and informative program. 

The speaker for the evening was David G. 
Hall, M.D., Chairman of the Department of Ob- 
Gyn at the University of Missouri School of Med- 
icine. Dr. Hall discussed, “The Stimulation of 
Labor.” A question and answer period followed 
his formal presentation. 

Robert J. Fleming, M.D., Secretary 


SIXTH DISTRICT 

O. B. BARGER, HARRISONVILLE, COUNCILOR 

West Central Missouri Medical Society 

The regular monthly meeting of the West 
Central Missouri Medical Society was held at 
the Nevada Country Club, Nevada, Thursday, 
November 14. The social hour for visitation 



Doctors and their wives enjoyed an excellent dinner. 

among the doctors and their wives was as usual 
very much enjoyed. This refreshing hour was 
followed by a fine steak dinner. 

President Edward Jones opened the program. 
The secretary read the minutes of the last meet- 
ing and brought forth some new business in re- 
gard to correspondence recently received from 
the District Office of the Missouri Division of 
Health in Springfield. Dr. Jones introduced our 
State Association President, Dr. Kenneth Holl- 
weg of Kansas City, who was making his official 
visit to our society. He presented a slide lecture 
on the organizational structure of the Missouri 
State Medical Association, giving us a well il- 
lustrated picture of our organization with its 
various committees, and the functions of the state 
organization as well as those of our county so- 
cieties and the AMA. We were sorrv that manv 


ADVERTISEMENTS 


47 





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48 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
January, 1964 




Drs. Pearse, Barger, Giesler, Jones, Hollweg and 
Wray visit after meeting adjourns. 

of the young members of our group were not 
present to hear his presentation. 

The report of the nominating committee, pre- 
viously appointed by Dr. Jones, was read. Dr. 
Carter W. Luter of Butler was presented for 
President; Dr. Wm. H. Elett, Appleton City, 
Vice President and Dr. Roy Pearse, Nevada, for 
Secretary-Treasurer. This slate of suggested of- 
ficers for 1964 was unanimously elected. 

With no further business at hand the society 
adjourned until its December meeting to be held 
in Butler. 

Carter W. Luter, M.D., Secretary 


Dr. Hollweg was the featured speaker. 


NINTH DISTRICT 

E. A. STRICKER, ST. JAMES, COUNCILOR 

Mid-Missouri County Medical Society 

The Mid-Missouri County Medical Society and 
the doctors’ wives held a dinner meeting at the 


Shepherd of the Hills Motel Restaurant at Leb- 
anon on Thursday night, November 14. Follow- 
ing the social hour and dinner Francis Maples, 
M.D. of Springfield, spoke to the group on “Gas- 
tric Hypothermia.” Dr. Maples illustrated his 
talk with a movie and slides. 

M. K. Underwood, M.D., Secretary 


TENTH DISTRICT 

W. D. ENGLISH, CARDWELL, COUNCILOR 

Perry County Medical Society 

A meeting of the Perry County Medical So- 
ciety was held on Thursday night, November 21, 
at the Perry County Memorial Hospital. The pri- 
mary purpose of the meeting was to discuss the 


The attendance was small but interested. 

possible hyphenation of Ste. Genevieve County 
with Perry County to form the Perry-Ste. Gene- 
vieve County Medical Society. Mr. Ray McIn- 
tyre, Field Secretary of the State Medical As- 
sociation, was present to discuss details of the 
matter with us. 

If this proposal is favorably considered it will 
be referred to the Council of the Missouri State 
Medical Association for approval or disapproval. 

Following a full discussion of the idea, the so- 
ciety adjourned taking the proposition under 
advisement. 

A. E. McDermott, M.D., Secretary 


Hair Permanently Removed by Electrolysis 

DOROTHY WORRELL, R.N. 

233 N. Vandeventer, St. Louis 
Telephone, Jefferson 3-9436 

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ADVERTISEMENTS 


49 



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From the 
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UNIVERSITY OF MISSOURI 
Trips and Talks 

Dr. Jerry William Brown, associate professor 
of Anatomy at the University of Missouri Medi- 
cal Center, presented a paper entitled, “The 
Development of the Anterior Olfactory Nucleus 
in the Bat,” on November 9 and 10 at the Univer- 
sity of Alabama Medical Center in Birmingham. 
The meeting held there was the Committee on 
the Comparative Anatomy of the Nervous Sys- 
tem and was attended by approximately 25 
neuroanatomists, neurologists and neurosurgeons. 

Dr. William T. Griffin, instructor in the De- 
partment of Obstetrics and Gynecology at the 
Medical Center, attended a symposium at Albu- 
querque, New Mexico. The meeting was spon- 
sored by Medical Education for National De- 
fense (MEND). The symposium was on “Medi- 
cal Aspects of Nuclear Energy.” 

Dr. David G. Hall, professor and chairman, 
and Dr. Russell E. Hanlon, assistant professor, 
both of the Department of Obstetrics and Gyne- 
cology, attended a meeting of the Southern Med- 
ical Society in New Orleans on November 17 
through 22. Dr. Hall discussed a paper by Dr. 
Alois Vasicka on: “Use and Abuse of Oxytocics.” 

Dr. R. L. Russell, associate professor of the 
Department of Physiology and Pharmacology at 
the Medical Center, attended a MEND spon- 
sored program on Chemical and Biological De- 
fense at the Army Chemical School, Fort Mc- 
Clellan, Alabama, October 14 through 19. 

Dr. D. K. Meyer, professor of Physiology; Dr. 
M. L. Zatzman, associate professor of Physiology; 
Dr. J. L. Shields, instructor in Physiology; Mr. 
C. A. Robb and Mr. O. Lynn Webb, graduate 
students, attended a symposium on Transport 
Mechanisms, October 25 in St. Louis. 

Dr. David G. McDonald, assistant professor 
of Clinical Psychology, attended the meetings of 
the Society for Psychophysiological Research, 
October 11 in Detroit, Michigan. Approximately 
150 psychologists, psychiatrists and engineers at- 
tended the meeting. 

Dr. Robert E. Froelich, assistant professor of 
Psychiatry and head of Medical Communica- 
tions, attended a session on Advances in Photog- 
raphy in Medicine in Boston, Mass, on October 
14 and 16. The Society of Motion Picture and 


Television Engineers sponsored the meeting. 

Dr. Robert E. Froelich, assistant professor of 
Psychiatry and Dr. Rodman P. Kabrick, associate 
professor of Clinical Psychology, attended meet- 
ings dealing with Research into Medical Educa- 
tion, testing of students, and future of Medical 
Schools on October 28 through 30 in Chicago. 

Dr. James M. A. Weiss, professor and chair- 
man, and Dr. David Davis, associate professor, 
both of the Department of Psychiatry, were in- 
vited participants in an Institute on Training in 
Community Psychiatry, held at the University of 
Chicago, October 8 through 12. Representatives 
of 24 medical schools met to plan programs in 
the important new area of specialized training 
in community mental health. Following this 
meeting, Dr. Weiss served as an examiner for the 
American Board of Psychiatry and Neurology, 
and Dr. Davis was an invited guest at the or- 
ganizational meeting of the Illinois Group Psy- 
chotherapy Association. Both of the latter organ- 
izations also met in Chicago ( October 13 through 
16). 

Dr. James M. A. Weiss, professor and chair- 
man, and Dr. Jacob O. Sines, associate professor 
of clinical psychology, both of the Department 
of Psychiatry, presented a paper titled “Actuarial 
Analysis of Age-Related Problems of Psychiatric 
Patients” at the 16th annual meeting of the 
Gerontological Society in Boston, Mass., Satur- 
day, November 9. In this study, computer tech- 
niques were used to study relationships between 
personality characteristics and patterns on psy- 
chological tests in 532 patients seen on the psy- 
chiatric services at the University of Missouri 
Medical Center. This investigation appears to 
be the first large-scale project to demonstrate a 
clear-cut increase in frequency of depressive 
problems associated with age, and emphasized 
that depression, while relatively rare in child- 
hood, becomes more common in each successive 
age group through old age. Dr. Weiss read the 
paper, and was invested as a Fellow of the So- 
ciety at this meeting. 

Dr. Robert E. Froelich, assistant professor of 
Psychiatry, Dr. Rodman P. Kabrick, associate 
professor of Clinical Psychology, Dr. Donald 
Kausch, assistant professor of Clinical Psychol- 
ogy, and Mrs. Grace Sudderth attended a meet- 
ing of the Missouri Association for Mental Health 


50 


ADVERTISEMENTS 


51 


FRESH UP' with SEVEN-UP! 





52 


MISCELLANY 


Missouri Medicine 
January, 1964 


in Jefferson City on October 10 and 11. Dr. 
Froelich attended as a resource person for group 
discussions of problems in this state. Dr. Froe- 
lich also attended a meeting at the Annenberg 
School of Communication in Philadelphia, Pa. 
on October 17. Communication of Medical Re- 
search Activities to the public, other researchers 
and practitioners was discussed at the meeting. 

Dr. Gwilym S. Lodwick, asssociate dean of 
the School of Medicine and chairman of the De- 
partment of Radiology, will attend the Mid-Year 
meeting of the Trustees of the American Registry 
of Radiologic Technologists. Dr. Lodwick is 
Vice-President of this organization. The meeting 
will be held in Tucson, Arizona in late January. 
Also scheduled for January is a MEND confer- 
ence to be held in Pensacola, Fla. Dr. Lodwick 
as MEND Coordinator for the University of Mis- 
souri Medical Center will attend the meeting, 
tn February Dr. Lodwick will attend the Los 
Angeles Midwinter Radiologic Conference. He 
will participate with Dr. Ernest Aegerter of 
Philadelphia. 

Dr. Wayne Mason, resident physician in Radi- 
ology, Dr. William Wilson, residing physician 
in Radiology; and Dr. Gwilym S. Lodwick, pro- 


fessor and chairman of the Department of Radi- 
ology, attended the meeting of the American 
Roentgen Ray Society in Montreal, Canada. 

Dr. G. Ray Ridings, professor of Radiology 
(Radiation Therapy), recently attended a Can- 
cer Seminar at Penrose Hospital in Colorado 
Springs and a meeting of University Hospital 
Cancer Coordinators in New York. 

Dr. Gwilym S. Lodwick returned to Columbia 
after a dual engagement in Houston and Hon- 
olulu. fn Houston, Dr. Lodwick, accompanied 
by Dr. Riding, Dr. Haun, Dr. Bartlett, Dr. Tam, 
and Dr. Mason, was a guest participant in a 
symposium on bone at the M. D. Anderson Hos- 
pital. From Houston, he traveled to Honolulu 
where he was a guest of the Pan-Pacific Surgical 
Association and presented talks on tumors of 
bone. He left November 22 for Chicago and the 
meeting of the Radiological Society of North 
America, where he displayed an exhibit on com- 
puter diagnosis. Also attending this meeting were 
Drs. Cochran, Weintraub, Haun, Simmons, Rail 
and Mr. George Koenig. 

Dr. Gwilym S. Lodwick, professor and chair- 
man of the Department of Radiology and associ- 
ate dean of the School of Medicine, has also at- 




9 

increases 
blood flow 
to the brain 
* in the 
senility syndrome 
associated 
with 

cerebrovascular 
insufficiency 


Volume 61 
Number 1 


MISCELLANY 


53 


tended meetings in Endicott, New York and 
Rochester, New York. In Endicott, he attended 
the IBM Clincial Symposium and delivered a 
talk on “Computer Analysis of Tumor Roentgen- 
ograms. ’’ The Rochester meeting related to Civil 
Defense and Medical Education for National 
Defense. 

Dr. Henry McQuade, associate professor of 
Radiology, recently attended a Nuclear Reactor 
Symposium at Georgia Tech in Atlanta, Georgia. 

Mr. George Koenig attended an Institute for 
X-ray technicians in Dallas, Tex. late in October. 
He moderated a panel discussion on “Organiza- 
tion and Problems of an Approved Training 
School.” 

Dr. Kenneth Keown, professor of Anesthesiol- 
ogy, presented his paper “Anesthesia for Open 
Heart Surgery” and was a member of a Panel 
on Treatment of Benign Chest Conditions at a 
meeting sponsored by the Pan-Pacific Surgical 
Association in Honolulu on November 3 through 
10. His topic on this panel was “The Treatment 
of Acute Airway and Ventilation Problems.” 

Dr. G. W. N. Eggers, associate professor of 
Anesthesiology, and Dr. M. T. Metzgar, assistant 
professor of Anesthesiology attended the annual 


meeting of the American Society of Anesthesiol- 
ogists in Chicago, November 1 through 6. Dr. 
Eggers presented a refresher course entitled 
“Effects of Surgical Positioning.” 

Four papers and two exhibits were presented 
by the faculty and resident staff of the section of 
Urology at the Colorado Springs meeting of the 
American Urological Association on October 14 
through 17. Dr. Victor L. Robards, resident phy- 
sician in Urology, presented “Septicemia and 
Shock in Urology” and was awarded first prize 
in the residents’ essay contest. Dr. Edward L. 
Johnson, instructor in Surgery, was presented 
with a certificate of merit for his paper on “In- 
duced Hypertension in Rats.” The exhibit on 
“Renal Capsule Flap Pyeloplasty” prepared by 
Dr. Ian M. Thompson, professor of Surgery; Dr. 
Frank R. Michener, resident physician in Sur- 
gery, and Dr. Laszlo Kovacsi was awarded first 
prize for scientific exhibits. 

Dr. Edward L. Johnson, resident physician in 
Surgery, and Dr. Ian M. Thompson, professor 
of Surgery, both of the Section of Urology, and 
Dr. Victor Carnes, of the Department of Pathol- 
ogy, will present a paper on “The Effect of Urea 
in Experimental Pyelonephritis” at the American 



Inadequate cerebral blood flow — often due to cerebral arteriosclerosis — may 
result in the “senility syndrome" with its pattern of mental confusion, mem- 
ory lapses, depression, fatigue, apathy and behavior problems. 1 * 3 

43% increase in cerebral blood flow 4 

In patients with cerebrovascular insufficiency, Eisenberg4 measured a 43 per- 
cent increase in blood flow in the brain following administration of Arlidin 
(nylidrin HCI) orally for more than two weeks beginning with a dosage of 
12 mg. t.i.d. and increasing to 18 mg. t.i.d. There was a decrease in cerebral 
vascular resistance in most instances. 

Winsor and associates 3 found Arlidin (nylidrin HCI) “of particular value 
clinically in relieving some of the symptoms of cerebral vascular insufficiency 
(vertigo, lightheadedness, mental confusion, diplopia).” 

arlidin' 

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SUMMARY: Indicated whenever an increase in blood supply is desirable in 
circulatory insufficiencies of the extremities, brain, eye and ear. Use with 
caution in the presence of a recent myocardial lesion, severe angina pectoris 
and thyrotoxicosis. Contraindicated in acute myocardial infarction. 

REFERENCES: 1. Madow, L. : Penn. M. J. 62-861, June 1959. 2. Stieglitz, E. J.: Geriatric Medicine, 
ed. 2, Philadelphia, Saunders, 1949 p. 274. 3. Winsor, T., et al.: Amer. J. Med. Sciences 239:594, 
May 1960. 4. Eisenberg, S.: ibid, July 1960. 

u. s. vitamin & pharmaceutical corporation 

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54 


MISCELLANY 


Missouri Mumcink 
January, 1964 


College of Surgeons meeting in San Francisco. 
Also at the College meeting: Dr. Ian M. Thomp- 
son, and Dr. Gilbert Ross, assistant professor of 
Urology, presented exhibits delineating a new 
technique for the surgery of urethral stricture 
and a new operation for reconstruction of the 
uretero-pelvic junction. 

On November 4 through 8 Dr. Ian M. Thomp- 
son was a guest speaker at the Pan-Pacific Surgi- 
cal Association meeting in Honolulu, Hawaii. He 
spoke on the operation devised at the University 
of Missouri for urinary diversion, and partici- 
pated in a panel on Urinary Incontinence. Also 
in Hawaii, Dr. Thompson discussed “Recent De- 
velopments in Urology” at a meeting of the 
Western Urologic Forum preceding the Pan- 
Pacific meeting. 

Meetings 

A total of 220 professional people attended the 
Fourth Annual M.D. Day held at the University 
of Missouri Medical Center, November 15 and 
16. The total count was: Missouri— 187, Colo- 
rado— 1, Ohio— 2, Illinois— 7, Iowa— 4, Kansas— 6, 
Kentucky— 1, Oklahoma— 9, Oregon— 1, Texas— 1, 
and Florida— 1. The meeting consisted of several 
scientific meetings Friday and Saturday in addi- 
tion to a dinner Friday night and a luncheon Sat- 
urday noon. 

ST. LOUIS UNIVERSITY 
Mental Health Program 

“Medical Practice and Mental Health,” a prac- 
tical approach for non-psychiatric physicians will 
be presented by the Saint Louis University De- 
partment of Neurology and Psychiatry six Tues- 
day mornings from 8:00 to 10:00 a.m., February 
11 to March 17. The Continuing Medical Edu- 
cation Program is being presented with the as- 
sistance of the Advisory Council on Continuing 
Education in Mental Health at St. Louis Uni- 
versity. 

Fifty physicians can be accommodated in the 
six two hour sessions. Tuition fee is $35. Course 
director is Dr. Edward T. Auer, director, depart- 
ment of neurology and psychiatry and of the 
David P. Wohl Mental Health Institute. Sessions 
will be held in the Alexander Room of Rogers 
Hall, 3601 Lindell Blvd. Reservations may be 
made through Metropolitan College, Saint Louis 
University, 221 North Grand Blvd., or by calling 
Jefferson 5-3300, Ex. 355. 

The six sessions will offer a concise, practice 
survey of the role of emotional factors in patient 


management, designed for internists, obstetri- 
cians, general practitioners, pediatricians, oph- 
thalmologists, orthopedic surgeons and other 
non-psychiatric physicians. 

Broad aim of the program is to assist each 
physician in adding to his understanding of 
the role of social and psychologic factors in the 
etiology, diagnosis and treatment of the cases 
ordinarily met in the consulting room. Empha- 
sis throughout is on function and effect of emo- 
tional factors, rather than on theory or history 
of psychiatry. 

Lecturers in the program are drawn from the 
St. Louis University Medical Center, the De- 
partment of Neurology and Psychiatry, the De- 
partment of Pediatrics and Cardinal Glennon 
Memorial Hospital for Children. 

Lecture titles, participants and date of presen- 
tation are: “Comprehensive Medical Care and 
the Doctor-Patient Relationship,” Dr. Arnold 
Block, assistant professor of clinical neurology 
and psychiatry, February 11; “From Infancy to 
Senility— The Evolution of Emotional Problems 
Through the Lifespan,” Dr. Robert J. Corday, as- 
sistant professor of psychiatry and child psychi- 
atrist at Cardinal Glennon Memorial Hospital, 
February 18; “Sex and Marriage: Pre-Marital and 
Marital Counseling, The Unwed Mother,” Dr. 
Edward Auer, February 25; “Suicide, Depression 
and Related States,” Dr. Robert James Leider, 
assistant professor of psychiatry, March 3; “The 
Use and Abuse of Drugs in the Management of 
Emotional Problems,” Dr. Richard Quick, in- 
structor in psychiatry, March 10; Summary and 
Review: “A Case Study of Mental Retardation 
and Its Effect on the Total Family Situation,” 
panel, Dr. Corday, chairman; Dr. Austin R. 
Sharp, assistant professor of pediatrics and act- 
ing director of the department of pediatrics and 
pediatrician-director, Child Development Clinic; 
Dr. Allan G. Barclay, assistant professor of psy- 
chology and chief psychologist, Cardinal Glen- 
non Hospital; Audrey M. Thaman, clinical social 
worker; Mrs. Marian M. Joltgrewe, public health 
nurse consultant. 

Appointments 

The following faculty appointments have been 
announced by the Rev. Edward J. Drummond, 
S.J., vice president for the Medical Center at 
St. Louis University. 

Associate Professor: Dr. Harold J. Nicholas, 
biochemistry. 

Assistant Professor: Dr. Robert J. Corday, psy- 
chiatry; Dr. Joan Finkle de Pena, anthropology 
in the Department of Anatomy; Dr. Werner 



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56 


MISCELLANY 


Missouri Medicine 
January, 1964 


Fischleschweiger, anatomy; Dr. Julius T. Han- 
sen, physiology; Dr. George C. Kaiser, surgery; 
Dr. Harry G. Moore Jr., clinical psychiatry; Dr. 
Howard Yanof, physiology. 

Senior Instructor: George Benson, clinical 
neurology and psychiatry; Dr. Anthony L. Ferro, 
psychiatry; Dr. Thomas K. Mangelsdorf, psy- 
chiatry; Dr. Ivan Sletten, psychiatry; Dr. Elliot 
A. Wallach, dermatology. 

Instructor: Dr. Ralph L. Biddy, psychiatry; 
Dr. Bernell Coleman, physiology; Dr. Robert M. 
Donati, internal medicine; Sister Wilma Marie 
Haslag, S.S.M., physiology; Dr. John R. Hogan, 
internal medicine; Dr. Henry Hurd, orthopedic 
surgery; Dr. LeRoy L. Fink, surgery; Dr. John 
McDonough, internal medicine; Dr. Emil Fred- 
erick Miskovsky, internal medicine; Dr. Harold 
J. Ott II, obstetrics and gynecology; Dr. Ray- 
mond E. Probst, gynecology and obstetrics; Dr. 
Robert T. Quick, psychiatry; Dr. Paul Ritter, 
gynecology and obstetrics; Dr. Joseph S. Shu- 
man, psychiatry; Dr. Takeo Tsunekawa, surgery; 
Dr. Edward M. Wittgen, orthopedic surgery; 
Dr. Ralph E. Woods, gynecology and obstetrics. 

Assistants: Dr. Raymond J. Beidle, pediatrics; 
Dr. Joseph Boveri, gynecology and obstetrics; 
Miss Natalie Ann Connors, anatomy; Dr. John D. 
Goldkamp, pediatrics; Dr. Raymond Hellweg, 
pediatrics; Dr. George E. Humphrey, radiology; 


Dr. Paul N. Meiners, surgery; Dr. Hassan Nouri, 
gynecology and obstetrics; Dr. Edward S. Rader, 
urology; Dr. Herman Shyken, radiology; Dr. 
Edward Zukowski, radiology. 

Research Associate: Harry C. Eschenroeder, 
D.V.M., surgery; Dr. Hiroshi Fukaya, physiology; 
Dr. Kenkichi Oho, surgery and Takeshi Seno, 
microbiology. 

The Rev. J. Willis Averill, S.J., has been ap- 
pointed counselor for nursing and medical stu- 
dents with offices at the St. Louis University 
School of Medicine. 

Father Averill is former assistant dean of men 
at Creighton University in Omaha, where he 
taught philosophy and theology from 1944 to 
1953. While in Omaha, he also was visiting chap- 
lain for the psychiatric ward at St. Joseph’s 
Hospital. 

Mr. William N. Jones has been appointed con- 
troller of St. Louis University Hospitals, it has 
been announced by Mr. John B. Warner Jr., di- 
rector, St. Louis University Hospitals. 

Mr. Jones formerly was associated with the 
firm of Kerber, Eck and Brackel as accountant. 
He holds a bachelor of science degree in com- 
merce awarded by St. Louis University in 1956. 

In his new position, Mr. Jones will serve as 
controller for Firmin Desloge Hospital and David 
P. Wohl Memorial Mental Health Institute. 


ANNUAL CLINICAL CONFERENCE 

CHICAGO MEDICAL SOCIETY 
March 2, 3, 4 and 5, 1964 
Palmer House, Chicago 

Lectures Teaching Demonstrations 

Medical Color Telecasts Film Lectures 

Instructional Courses 


The Chicago Medical Society Annual Clinical Conference should be a 
MUST on the calendar of every physician. Plan now to attend and make 
your reservation at the Palmer House. 


Volume 61 
Number 1 


MISCELLANY 


57 


In the News 

Dr. Maurice Green, professor of microbiology, 
St. Louis University School of Medicine, de- 
livered a paper entitled “Biochemistry Studies 
on Human Tumorigenic Adenoviruses” before 
the Southwest Section of the American Associa- 
tion for Cancer Research, which met in Houston, 
Texas November 8 and 9. He also spoke at Bay- 
lor University on the same subject on Novem- 
ber 7. 

Dr. Rene Wegria, director, department of 
pharmacology, recently lectured on his new in- 
vestigation concerning the “Pathogenesis of Car- 
diac Edema” at the Columbia University College 
of Physicians and Surgeons in New York City. 

Dr. Armand E. Brodeur, associate professor of 
radiology, addressed the American Public Health 
Association in Kansas City on Nov. 14. 

Dr. C. Rollins Hanlon, director, department 
of surgery, attended the meeting of the Western 
Surgical Association held in Galveston, Texas, 
on November 22. 

Dr. Daniel Sexton, associate professor of clin- 
ical medicine, was honored as president of the 
Southern Medical Association by St. Louis Uni- 
versity medical alumni in New Orleans on No- 
vember 19. 

Award 

Robert G. Trinity, a junior student at the St. 
Louis University School of Medicine, has been 
awarded the annual Roche Award presented by 
Roche Laboratories. 

Trinity has received a gold wrist watch and 
scroll, embossed with the seal of the St. Louis 
University School of Medicine. 

The award is presented annually to a medical 
student who has completed two years of study, 
in recognition of outstanding scholarship, char- 
acter and personality. 

Trinity was awarded his Bachelor of Science 
degree in 1961 by Loyola University in Los An- 
geles. He is a member of Phi Chi Medical Fra- 
ternity. 

School Press Workshop 

The School of Medicine served as host to edi- 
tors of high school papers in St. Louis and St. 
Louis County on Oct. 30. The 27th Annual 
School Press workshop was sponsored by Co- 
lumbia Scholastic Press Association, National 
Tuberculosis Association and the Tuberculosis 
and Health Society of St. Louis. The program 
included a welcome by Dr. John P. Wyatt, di- 
rector, department of pathology, and a tour of 
the department by Dr. Richard Dames, assistant 
to the dean. Dr. Chao Sun, assistant professor of 


reduce 

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58 


MISCELLANY 


Missouri Medicine 
January, 1964 


pathology, demonstrated the electron microscope. 
Dr. Dames spoke to the group on “Health Ca- 
reers” and participated in a question and answer 
session. Rex Davis, News Director of KMOX 
radio, spoke on “How to Produce News Stories, 
Features and Editorials.” 

ELLIS FISCHEL STATE CANCER 
HOSPITAL 

Dr. Rupert B. Turnbull, Chief of Proctology 
and Colon Surgery, Cleveland Clinic, was visit- 
ing surgeon October 18, 1963. 

The Combined Conference of the American 
Cancer Society, Missouri Division, and the Con- 
sulting Staff of the Ellis Fischel State Cancer 
Hospital was attended by the Consulting Staff 
and referring physicians October 19-20, 1963. 

Dr. John S. Spratt, Chief Surgeon, attended 
the Clinical Congress of the American College 
of Surgeons in San Francisco as Liaison Fellow 
from Missouri, Committee on Cancer, October 
28-November 1, 1963. 

Dr. John S. Spratt, Chief Surgeon, was Guest 
Panelist at the 15th Annual Cancer Seminar, Pen- 
rose Cancer Hospital, Colorado Springs, Colo- 
rado, November 2, 1963. The subject of the panel 
was intestinal neoplasms. 

Dr. William Shieber, St. Louis, Missouri, dem- 
onstrated pelvic lymphangiographic techniques 
to the resident staff of the Ellis Fischel Hospital, 
November 14, 1963. 

Dr. A. McChesney Evans, Chief of Internal 
Medicine at the Ellis Fischel State Cancer Hos- 
pital addressed the Morgan County unit of the 
American Cancer Society at Versailles, Missouri 
on November 15, 1963. He spoke at the new City 
Hall Building on the subject “Cancer Research 
and the American Cancer Society.” 

Dr. Raul Mercado and Dr. Jose Castells, 
Radiotherapists at Ellis Fischel State Cancer 
Hospital, recently attended the Radiological So- 
ciety of North America Meeting in Chicago, Illi- 
nois. Dr. Castells was co-author of a paper with 
Dr. Isadore Meschan of Winston-Salem, North 
Carolina concerning “Studies on D.N.A. Syn- 
thesis in Regenerating Rat Liver,” which was 
presented at the meeting. 

Dr. Jose M. Sala, former Radiotherapist at 
Ellis Fischel State Cancer Hospital, presented a 
paper “The Detection and Treatment of Post- 
Irradiationally Recidivated Carcinomas of the 


Cervix Uteri” which was prepared here by Dr. 
Ronald K. Gary, Dr. John S. Spratt and himself. 

Dr. Carlos Perez-Mesa, Pathologist at Ellis 
Fischel State Cancer Hospital, presented a paper 
entiled “Hormonal Influences on Testicular 
Morphology,” written in collaboration with Dr. 
Marvin W. Woodruff, Chief of Urology, Roswell 
Park Institute, Buffalo, New York, at the confer- 
ence of the Northeastern Section of the American 
Urological Association, held at the Chateau 
Frontenac Hotel, Quebec Citv, Canada, Septem- 
ber 22-25, 1963. 


SABIN ON SUNDAY IN METROPOLITAN 
ST. LOUIS 

Sunday, November 24, 1963, was the date 
when an estimated 308,000 St. Louisians and St. 
Louis Countians received the first of two oral 
Sabin vaccines. The second dose is to be given 
on Sunday, January 26, 1964. 

The Sabin on Sunday campaign was made 
possible by the cooperation of the St. Louis City 
and St. Louis County Medical Societies. The 
doctors of the area, numbering about 2,000, do- 
nated their services, as did some 14,000 other 
ancillary workers at the 190 vaccine stations in 
St. Louis and St. Louis County. Many of the pub- 
lic and parochial schools scattered throughout 
the area were used as the vaccine stations. 

Though the number receiving the vaccine fell 
short of the anticipated 600,000 goal, the drive 
was considered a success. In a statement released 
to the press, City-County Medical Charities, Inc., 
formed by the two St. Louis area medical so- 
cieties to handle the program, had this to say: 
“We are most happy that so many participated 
in the program, considering the public’s concern 
and mourning over the death of President Ken- 
nedy. We have immunized more than 300,000 of 
our fellow citizens. We are particularly grateful 
as members of area medical societies to the thou- 
sands of community minded St. Louis area resi- 
dents who joined us in donating their services 
to make this campaign a possibility.” 

Voluntary contributions of 50 cents per dose 
were requested to help defray the costs of the 
vaccine and distribution, however, no one was 
refused the vaccine who could not pay the small 
contribution. 


Volume 61 
Number 1 


MISCELLANY 


61 


NEW MEMBERS 

Daniel D. Beard, M.D., 1431 Claytonia Ter- 
race, St. Louis, has become a member of St. 
Louis Medical Society. Dr. Beard is a native 
of Decatur, Illinois, received his preliminary 
education at DePauw University, and his M.D. 
degree as Washington University in 1961. He 
specializes in internal medicine. 

Richard J. Kloecker, M.D., 9616 Lackland 
Road, St. Louis, has become a member of St. 
Louis Medical Society. Dr. Kloecker is a native 
of Omaha, Nebraska, received his preliminary 
education at Notre Dame University, and his 
M.D. degree at Loyola University in 1954. He 
specializes in surgery. 

R. W. Litwiller, M.D., 905 Virginia Ave., Co- 
lumbia, has become a member of Boone County 
Medical Society. Dr. Litwiller is a native of Mor- 
ton, Illinois, received his preliminary education 
at Goshen and University of Chicago, and his 
M.D. degree at Loyola University in 1945. He 
specializes in general practice. 

Amando Menendez Jr., M.D., 11084 Eckel- 
kamy Drive, St. Louis, has become a member of 
St. Louis Medical Society. Dr. Menendez is a 
native of Havana, Cuba, received his preliminary 
education at Marti Academy and his M.D. de- 
gree at Havana Medical School in 1956. He spe- 
cializes in pathology. 

Nolan B. Pitsinger, M.D., 5502 Delmar Blvd., 
St. Louis, has become a member of St. Louis 
Medical Society. Dr. Pitsinger is a native of Day- 
ton, Ohio, received his preliminary education 
at the University of Dayton, and his M.D. degree 
at St. Louis University in 1960. He specializes in 
surgery. 

Thomas J. Ridzon, M.D., 625 Lammert Ct., 
St. Charles, has become a member of Lincoln- 
St. Charles County Medical Society. Dr. Ridzon 
is a native of Bergholz, Ohio, received his pre- 
liminary education at Western Reserve Univer- 
sity, and his M.D. degree at St. Louis University 
in 1959. He specializes in internal medicine. 

J. William Thompson III, M.D., 524 Warder 
St., University City, has become a member of 
St. Louis Medical Society. Dr. Thompson is a 
native of St. Louis, Missouri, received his prelim- 
inary education at Amherst College, and his 
M.D. degree at St. Louis University in 1954. He 
specializes in thoracic surgery. 


Now! 14 x 17 X-ray or Medical Record Cabinets within 
price range of open shelving with panel back-sliding doors. 
ADD A FILE — 2 compartment, $70.00 F.O.B. factory in 
Illinois. 

Examining Furniture — Diathermy — Microtherm 
Birtcher Cardiograph — Whirlpools— Hanovia Lamps 

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angina patient 
better than 
vasodilators alone 

‘Miltrate’ contains both pentaerythritol 
tetranitrate, which dilates the patient’s 
coronary arteries, and meprobamate, 
which relieves his anxiety about his con- 
dition. Thus ‘Miltrate’ protects your angi- 
na patient better than vasodilators alone. 

Pentaerythritol tetranitrate may infre- 
quently cause nausea and mild headache, 
usually transient. Slight drowsiness may 
occur with meprobamate and, rarely, al- 
lergic reactions. Meprobamate may in- 
crease effects of excessive alcohol. Con- 
sider possibility of dependence, particu- 
larly in patients with history of drug or 
alcohol addiction. Like all nitrate-con- 
taining drugs, ‘Miltrate’ should be given 
with caution in glaucoma. 

Dosage: 1 or 2 tablets before meals and at bed- 
time. Individualization required. 

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Missouri Medical Meetings 


Missouri State Medical Association, Hotel Chase, St. Louis, 
March 8-11, 1964. 

Missouri Academy of General Practice, Hotel Chase, St. Louis, 
Oct. 31-Nov. 1, 1964. 

Component Society Meeting Dates 

Audrain County Medical Society — third Monday of each month. 

Barton-Dade County Medical Society — third Wednesday of each 
month. 

Benton County Medical Society — meets only on call. 

Boone County Medical Society — first Tuesday of each month. 

Buchanan County Medical Society — first Wednesday of each 
month. 

Butler-Ripley-Wayne County Medical Society — first Wednesday 
of each month. 

Callaway County Medical Society — third Thursday of each month. 

Cape Girardeau County Medical Society — first Monday of each 
month. 

Chariton-Macon-Monroe-Randolph County Medical Society — sec- 
ond Thursday of each month, September through May. 

Clay County Medical Society — last Tuesday of each month. 

Clinton County Medical Society — meets only on call. 

Cole County Medical Society — fourth Tuesday of each month. 

Cooper County Medical Society — first Monday after the 15th 
of each month. 

Dallas-Hickory-Polk County Medical Society — first Wednesday of 
each month. 

Dunklin County Medical Society — first Tuesday of each month. 

Franklin-Gasconade-Warren County Medical Society — first Tues- 
day of each month at the St. Francis Hospital, Washington, 
at 7 :00 p.m. 

Grand River Medical Society ( Caldwell-Carroll-Livingston, Grundy- 
Daviess, Harrison, Linn, Mercer, DeKalb) — second Thursday 
of each month. 

Greene County Medical Society — fourth Friday of each month. 

Henry County Medical Society — meets only on call. 

Howard County Medical Society— meets only on call. 

Jackson County Medical Society— March, May, October and 
December. 

Jasper County Medical Society — second Tuesday of each month, 
September through May. 


Jefferson County Medical Society — meets fourth Tuesday of each 
month. 

Johnson County Medical Society — meets only on call. 

Lafayette-Ray County Medical Society — second Tuesday of each 
month at 7 :30 p.m., at the Victory Cafe, Lexington. 

Lewis-Clark-Scotland County Medical Society — meets only on 
call. 

Lincoln-St. Charles County Medical Society — fourth Tuesday of 
each month. 

Marion-Ralls-Shelby County Medical Society — third Tuesday of 
each month, 7 :30 p.m. 

Mid-Missouri County Medical Society (Phelps-Crawford-Dent- 
Pulaski-Maries-Laclede) — fourth Thursday of each month. 

Miller County Medical Society — meets only on call. 

Mineral Area County Medical Society (St. Francois-Iron-Madi- 
son-Washington-Reynolds-Ste. Genevieve) — fourth Thursday of 
each month. 

Moniteau County Medical Society — second Thursday of each 
month. 

Nodaway-Holt-Atchison-Gentry-Worth County Medical Society — 
second Tuesday of each month. 

North Central Counties Medical Society ( Adair-Schuyler-Knox- 
Sullivan-Putnam) — meets only on call. 

Ozarks Medical Society ( Barry-Lawrence-Stone-Christian-Taney- 
Newton-McDonald) — second Tuesday of each month, Septem- 
ber through June. 

Pemiscot County Medical Society — third Thursday of each month. 

Perry County Medical Society — second Thursday of each month. 

Pettis County Medical Society — third Monday each month, Sep- 
tember through May. 

Pike County Medical Society — third Tuesday of each month. 

Platte County Medical Society — meets only on call. 

St. Louis County Medical Society — second and fourth Wednesday 
of each month. 

St. Louis Medical Society — third Tuesday of each month, October 
through May. 

Semo County Medical Society (Stoddard, New Madrid, Mississip- 
pi, Scott) — third Wednesday of each month, September through 
May. 

South Central Counties Medical Society ( Howell-Oregon-Texas- 
Wright-Douglass-Ozark) — fourth Wednesday of each month. 

Webster County Medical Society — meets only on call. 

West Central Missouri Society ( Bates-Cass-St. Clair-Vernon-Ce- 
dar) — second Thursday of each month. 



TREATMENT 

OF 

ALCOHOLISM 

In-patient and out-patient treatment to help the excessive 
user of alcoholic beverages gain and maintain abstinence for the 
balance of his life. Treatment regimen drawn up individually for 
each patient. Your referrals welcomed. 

Established 1897 by Benjamin Burroughs Ralph , M.D. 


RALPH CLINIC 

529 HIGHLAND AVE., KANSAS CITY 42, MISSOURI 
Phone: Victor 2-3622 P.O. Box 2597 

RALPH EMERSON DUNCAN, M.D. 

Medical Director 


Write for 
Free Portfolio 
on 


ALCOHOLISM 


We invite consultation with you concerning your 
patients with problems of excessive drinking 


62 



who were the 
‘untreatables”? 


From their inception with cortisone, to the present- 
day variants of the steroid molecule, the corticoster- 
oids have presented a therapeutic paradox. The 
beneficial action against inflammation and allergy as 
well as several undesirable metabolic effects are all, 
apparently, the results of the same basic physiologic 
action. 1 

Some of these associated metabolic reactions made it 
risky or otherwise undesirable to treat with steroids 
large numbers of patients in various categories who 
would otherwise have benefited from such manage- 
ment. These “untreatables” were overweight, had 
cardiac disease, hypertension, or pulmonary fibrosis 
associated with congestive heart failure. Also in 
this category were those patients whose emotional 
symptoms were aggravated by earlier steroids. 

But the advent of ARISTOCORT® Triamcinolone in 
1958 — the result of biochemical and pharmacologic 
research which successfully stripped away many 
important undesirable hormonal effects from the 
primary anti-inflammatory action — dramatically 
changed this picture. This steroid did not overstimu- 
late the appetite, or cause the excessive weight gain 
induced by other steroids; 2 ’ 7 it proved to have one of 
the best records of any steroid for not causing edema, 
or salt-and-water retention j 2 - 3 - 7 ’ 10 and the incidence 
of undesirable euphoria with this agent was remark- 
ably low. 2 - 4 - 5 - 9 - 10 What is most significant is that these 
benefits have stood the test of more than 5 years of 
widespread use. And, of course, the avoidance of 
these distressing hormonal effects benefited all pa- 
tients requiring steroids, not just those in the special 
categories, as demonstrated by wide clinical use. 


Side Effects. Since it may, under some circumstances, 
produce any of the unwanted effects common to all 
cortisone-like drugs, discrimination should always be 
exercised in administering ARISTOCORT® Triam- 
cinolone. Any of the Cushingoid effects are possible, 
as are purpura, G.I. ulceration, increased intracranial 
pressure and subcapsular cataract. Corticosteroids 
generally may mask outward signs of bacterial or 
viral infections. Catabolic effects to watch for include 
muscle weakness and osteoporosis. Weight loss may 
occur early in treatment but is usually self-limiting. 

Contraindications. While the only absolute contra- 
indications are tuberculosis and herpes simplex, there 
are some relative contraindications (peptic ulcer, 
glomerulonephritis, myasthenia gravis, osteoporosis, 
fresh intestinal anastomoses, diverticulitis, throm- 
bophlebitis, psychic disturbance, pregnancy, infec- 
tion) to weigh against expected benefits. 

While no steroid can cure a susceptible disorder, 
many patients who would otherwise be confined in a 
state of invalidism have, on ARISTOCORT® Triam- 
cinolone, been able to pursue active, useful lives. 

References: 1. Levine, R. : Rationale for the Use of Adrenal Steroids, 
Paper presented at Annual Convention, Medical Society of the State 
of New York, New York, May 13-17, 1963. 2. Hollander, J. L. : Clinical 
Use of Dexamethasone. JAMA 172: 306 (Jan. 23) 1960. 3. Boland, 
E. W.: Chemically Modified Adrenocortical Steroids. JAMA 17i: 835 
(Oct. 15) 1960. 4. McGavack, T. H.: The Newer Synthetic Adreno- 
cortical Steroids in Therapy. Nebraska Med. J. 44:377 (Aug.) 1959. 5. 
Freyberg, R. H.: Berntsen, C. A., Jr., and Heilman, L.: Further Ex- 
periences with Al, 9 Alpha Fluoro, 16 Alpha Hydroxyhydrocortisone 
(Triamcinolone) in Treatment of Patients with Rheumatoid Arthritis. 
Arthritis Rheum. 1:215 (June) 1958. 6. Cahn, M. M. and Levy, E. J.: 
Triamcinolone in the Treatment of Dermatoses. Amer. Practit. 10: 99 J 
(June) 1959. 7. AMA Council on Drugs: New and Nonofficial Drugs. 
JAMA 169: 255 (Jan. 17) 1959. 8. McGavack, T. H.; Kao, K.-Y. T.; 
Leake, D. A.; Bauer, H. G., and Berger, H. E.: Clinical Experiences 
with Triamcinolone in Elderly Men. Amer. J. Med. Sci. 236: 720 (Dec.) 
1958. 9. Fernandez-Herlihy, L.: III. Use and Abuse of Corticosteroid 
Therapy-The Structure and Biologic Activity of the Corticosteroid 
Hormones and ACTH, Med. Clin. N. Amer. 44:509 (Mar.) 1960. 10. 
McGavack, T. H.: Triamcinolone: A Potent Anti-inflammatory Sodium 
Excreting Adrenosteroid. Clin. Med. 6: 997 (June) 1959. 


maximum steroid benefit-minimum steroid penalty 


Aristocort 

Triamcinolone 

1 mg., 2 mg. or 4 mg. tablets. 


LEDERLE LABORATORIES 


A Division of AMERICAN CYANAMID COMPANY, Pearl River, New York 

229 -» 


LEO H. POLLOCK, M.D. 

Missouri Medicine in Review 



FORTY YEARS AGO 

An endowment of $650,000 has been appropri- 
ated to the St. Louis Maternity Hospital by the 
General Education Board founded by John D. 
Rockefeller. The donation is contingent upon the 
erection of a new building for the hospital to 
cost $500,000, to be paid for by subscriptions 
from other sources. 

News dispatches from Liberty, Mo., state that 
the Clay County grand jury has indicted 16 per- 
sons presumably for practicing medicine without 
a license. Most of the evidence in the cases was 
obtained through Clay County Medical Society. 

The Board of Aldermen of St. Louis are con- 
sidering an ordinance authorizing the Hospital 
Commissioner to require patients admitted to the 
City Hospital to pay $2.20 a day for their care 
when it is found that the patients are able to 
do so. 

Dr. David Pres wick Barr, of Cornell Univer- 
sity, has been appointed Busch professor of med- 
icine in Washington University Medical School 
and physician in chief to the Barnes Hospital. 
The appointment will become effective February 
1, but Dr. Barr will not assume active duties in 
the school until September. 

Dr. Johannes Fibiger, professor ordinarius in 
pathological anatomy at the University of Copen- 
hagen, has demonstrated, following repeated ex- 
perimentation, that parasites play an important 
role in the formation of certain types of tumors 
in the preventriculi of rats. Furthermore, he has 
succeeded in effecting papillomata and un- 
doubted carcinoma through the parasite nema- 
tode. 

TWENTY-FIVE YEARS AGO 

Drs. Millard F. Arbuckle and Brian Blades, St. 
Louis, were guests of the Southwest Missouri 
Medical Society at Springfield on December 2. 


The Hodgen Lecture, sponsored by the St. 
Louis Surgical Society, will be presented on 
January 10. Dr. F. T. Coller, Ann Arbor, Profes- 
sor of Surgery, University of Michigan, will pre- 
sent the address on “Studies on Altered Chem- 
istry in Surgical Patients.” 

The honor roll, composed of component so- 
cieties all of whose members paid dues for the 
current year, was creditably long at the close of 
1938. Jackson County Medical Society, for the 
first time since 1933, reported all members paid 
for the current year. County societies on the 
honor roll are Jackson, Chariton, Perry, Ste. Gen- 
evieve, Camden, Webster, Montgomery, Dent, 
Miller, Moniteau, Morgan, Macon, Pulaski, How- 
ard, Andrew, Bates. 

Dr. M. Pinson Neal, Columbia, was installed 
as president of the Mississippi Valley Medical 
Society at the annual meeting of the society at 
Quincy, 111., in November. Missouri members 
elected to offices in the society are Dr. Joel W. 
Hardesty, Hannibal, first vice president; Drs. 
W. L. Hanson and Q. U. Newell, St. Louis, Ed- 
mund Lissack, Concordia, Dan G. Stine, Colum- 
bia, and F. E. Sultzman, Hannibal, members of 
the board of directors. 

The Missouri State Medical Association will 
submit to the January, 1939 General Assembly 
of Missouri a fair and impartial basic science act 
which would require a uniform standard of 
training for all who wish to practice the healing 
art. 

Tularemia has been a subject of considerable 
interest in the state during the last several weeks. 
The State Health Commissioner, through the 
daily and weekly press, warned Missourians to 
exercise special care in dressing rabbits and 
quail and to call a physician whenever symptoms 
appear. A few fatalities have been reported. 

Construction of the new State Trachoma Hos- 
pital at Rolla has been started. This will be the 
only state hospital maintained exclusively for the 
treatment of trachoma patients. The contract 
calls for an expenditure of $104,575. Dr. J. E. 
Smith is superintendent of the Trachoma Hos- 
pital. 

TEN YEARS AGO 

In a dignified atmosphere of almost perfect 
equanimity and without recourse to action en- 
couraging unwanted publicity or pictures in the 
66 


Contents for February 1964 

Scientific Articles: 

Some Psychiatric Aspects of Convulsive 
Disorders, Louis L. Tureen, M.D., and 
Robert M. Woolsey, M.D., St. Louis . 91 

Fat Embolism: A Postoperative Complica- 
tion, Paul O. Hagemann, M.D., Billy Ben 
Baumann, M.D., and L. S. N. Walsh, 

M.D., St. Louis 99 

The First Minute of Life: A Physiologic 
Review, Thomas M. Mier, M.D., and 
Raymond E. Probst, M.D., St. Louis . 103 

Special Articles: 


AM A Clinical Session, Arthur W. Neilson, 

M.D., St. Louis 108 

Thermonuclear Survival, Solomon Garb, 

M.D., Columbia Ill 


Departmental Features: 

Washington 78 

Across Missouri 82 

Missouri Academy of General Practice . 84 

Woman’s Auxiliary 88 

President’s Message 118 

Editorial 119 

Deaths 119 

News-Personal and Professional . . . 120 

Ramblings of the Field Secretary . . . 122 

Missouri State Medical Association Pro- 
gram 124 

New Members 130 

County Society News 134 

The Council 138 

From the Medical Schools 152 


Editorial and Business Office, 634 N. Grand Blvd., St. Louis 3, Mo. Copyright 1964 by Missouri State Medical Association. All 
rights reserved. Second-class postage paid at Fulton, Missouri. Published monthly, except semi-monthly in July, by the Missouri 
State Medical Association at 1201-05 Bluff Street, Fulton, Missouri. Subscription Price: $3.00 Per Year. Printed by The Ovid 
Bell Press, Inc., Fulton, Missouri. 


Information for Contributors 


Articles are accepted for publication on condi- 
tion that they are contributed solely to this jour- 
nal. Material appearing in Missouri Medicine is 
protected by copyright. Permission will be granted 
on request for reproduction in reputable publica- 
tions provided proper credit is given and author 
gives permission. 

Manuscripts should be typewritten, double 
spaced, and the original with one carbon copy sub- 
mitted. Retain another carbon copy for proofread- 
ing. Used manuscripts are not returned. School and 
hospital appointments of the author should ac- 
company the manuscript. It is desirable that a 
synopsis-abstract of approximately 135 words ac- 
company the manuscript. Bibliography should be 
arranged at the end of the article in the order in 
which the references are cited in the text. The 
reference should give name of author, title of ar- 
ticle, name of periodical, volume number, initial 
page number and year. Authors are responsible 
for bibliographic accuracy. Bibliography should 
be double spaced. 

Illustrations should be glossy prints or draw- 
ings in India ink on white paper. They should 


not be mounted and name of author and figure 
number should be penciled lightly on the backs. 
Legends should appear on a separate sheet. 
Colored illustrations will be used when suitable 
if author assumes the actual cost. 

Legal difficulties may arise from unauthorized 
use of names, initials or photographs in which in- 
dividuals can be identified. Permission should be 
secured from patient or legal guardian and signed 
duplicate or photostat submitted with such photo- 
graphs or identification. The Editor and Editorial 
Board assume no responsibility for the opinions 
and claims expressed in articles contributed by 
authors. If citation of an institution related to the 
article is made, approval of the chief of service 
should be given in a letter accompanying the 
article. 

Reprint order blanks will accompany proof, 
which will be sent to authors prior to publication. 

All material other than scientific should be re- 
ceived prior to the first of the month preceding 
month of publication. 

Please give notice of change of address at least 
one month in advance of the change, giving old 
and new addresses. 


77 



Proposals to provide limited health care for 
the aged under social security continue to be 
the most important legislation before Congress 
so far as the medical profession is concerned. 

In his State of the Union message to Congress, 
President Johnson labeled it “must’’ legislation 
and asked for Congressional approval before 
the end of this summer. 

The House Ways and Means Committee late 
in January wound up hearings on the King- 
Anderson bill, the Administration’s medicare 
legislation. The hearings had been interrupted 
by President Kennedy’s assassination. 

The committee— with a majority of its mem- 
bers believed to still be opposed to such legis- 
lation— did not indicate immediately when it 
would act further on the bill. 

In commenting on the State of the Union mes- 
sage, Dr. Edward R. Annis, President of the 
AMA, said that President Johnson apparently 
had been misinformed by his advisers on the 
legislation. 

“Medicare would not be an insurance program 
for health care for the elderly, and workers 
would not contribute to a fund for their old 
age,” Dr. Annis said. 

“Medicare would be strictly a tax program, 
forcing wage earners to pay a substantial in- 
crease in their payroll taxes to finance hospital- 
ization for everyone over 65, including those 
who are wealthy and millions of others who al- 
ready are protected with hospital insurance. 

“The President has also been misinformed on 
the cost of such a program. Testimony of the 
Chief Actuary of the Social Security Administra- 
tion before the Ways and Means Committee in 
November shows that every worker earning one 
hundred dollars or more a week would be forced 
to pay at least 23 per cent more in payroll taxes 
to finance this inequitable program. 

“Medicare is unnecessary. Private health insur- 
ance, now protecting more than 10 million elder- 
ly, is available to those who can pay their own 
way, and the Kerr-Mills Law, already enacted in 
more than 40 states, can help those who need 
help.” 

Other legislative proposals of interest to phy- 
sicians include: 

An amendment to the Keogh law that would 
remove the present 50 per cent limitation on 


the amount of income tax deduction a self-em- 
ployed person can claim on his annual retirement 
savings. It also removes the $2,500 or 10 per 
cent of income limitation on the amount of re- 
tirement savings an individual with employees 
could use for tax deduction purposes. This would 
be a tremendous boost for the Keogh program 
and for self-employed persons with retirement 
savings plans. 

Rep. Eugene Keogh (D., N. Y. ) and Sen. 
George Smathers (D., Fla.) are sponsoring the 
amendment. 

The Internal Revenue Service recently issued 
a tentative ruling that was a setback to phy- 
sicians and other professional men planning to 
band together into corporations for tax pur- 
poses. A proposed regulation stated that such 
professional organizations must have all of the 
characteristics of a business corporation in order 
to qualify for corporation tax treatment, which 
would be virtually impossible for a group of 
professional men. 

The regulation would knock out the so-called 
Kintner regulations of 1960 under which IRS 
stated that associations of professional men 
would be classified for tax purposes as corpora- 
tions provided certain corporate characteristics 
were followed and provided that state law au- 
thorized establishment of the groups as corpora- 
tions. 

The IRS proposal is not final and will be the 
subject of hearings at a later date. It appears 
certain to be the subject of court litigation, if 
made final. 

A civil defense bill that has passed the House 
and is before the Senate would provide a $190 
million program of grants to hospitals and other 
non-profit institutions for building fall-out shel- 
ters. These shelters could be used as garages, 
storage areas and such in peacetime. 

An Administration proposal would require 
clearance and approval of new medical devices, 
which means anything from a new ty pe of for- 
ceps to the most complicated radiation device. 
FDA would rule on the efficacy as well as the 
safety of such devices, as it does now on new 
drugs. 

An amendment to the medical education law 
would forgive part of the repayment of federal 
loans to students if the young physician settles 
in a physician-shortage area. 

Last year Congress cut the National Institutes 
budget request by $12 million in approving $918 
million for NIH. This was the first time in re- 
cent years Congress has failed to substantially 
increase the NIH budget request of the Admin- 
istration. 


7S 



rthritic joints from 



' arthritis, rheumatoid spondylitis, osteoar- 
5, bursitis, fibrositis, and neuritis. Arthralgen 
be used for analgesia in colds, flu, and 
js myalgias. 

^GE: One or two tablets four times a day. 
remission of symptoms, dosage should be 
:ed to the minimum maintenance level. 

EFFECTS: Nausea, Gl upset, or mild salicy- 
nay rarely occur. Symptomsof hypercorticoid- 
iictate reduction of dosage of Arthralgen-PR. 

CAUTION: Reduction in dosage of Arthral- 
°R given over a long period should be gradual, 
r abrupt. 

TRAINDICATIONS: Hypersensitivity to any 
(idient. 

'ith any drug containing prednisone, Arthral- 
PR is contraindicated, or should be adminis- 


tered only with care, to patients with peptic ulcer, 
tuberculosis, nephritis, diabetes mellitus, acute 
psychoses, Cushing's syndrome (or Cushing’s 
disease), overwhelming spreading (systemic) in- 
fection, or predisposition to thrombophlebitis. 

Arthralgen-PR is generally contraindicated in 
patients with uremia and viral infections, including 
poliomyelitis, vaccinia, ocular herpes simplex, and 
fungus infections of the eye. It is also contraindi- 
cated in patients with chicken pox or susceptible 
persons exposed to it. 

SUPPLY: Arthralgen (white, scored) and Arthral- 
gen-PR (yellow, scored) tablets are available in 
bottles of 100 and 500. 

*Cohen, et al: J.A.M.A., 165:225, 1957. 

A. H. ROBINS CO., INC. 

RICHMOND, VIRGINIA 



Missouri’s Voting Law Better Than Some 

Missouri is one of 16 states which have en- 
acted, introduced or are planning legislation to 
reduce or waive minimum residency requirements 
for new residents. Twelve of these states have a 
residence requirement of six months for new- 
comers, while Missouri requires one year. 

An article in the January issue of Today’s 
Health estimates that outmoded registration and 
election laws keep millions of eligible voters 
from the polls. 

“A paper curtain, in the form of outmoded 
registration and election laws, keeps many of our 
most responsible citizens from voting,” the ar- 
ticle states. 

“In 1960, it is estimated, at least 20 million 
Americans— half of all those of voting age who 
did not vote— were disfranchised in this manner. 

“They included persons who were ill, confined 
to nursing homes or other institutions, were 
traveling on business or vacation, or were victims 
of racial discrimination. But the largest group— 
an estimated eight million persons— had done 
nothing more unusual than move in the weeks 
and months preceding election day, and then 
found themselves denied an opportunity to reg- 
ister and vote in either their old or new places 
of residence.” 

A “shocking proportion” of Americans— per- 
haps one third of the electorate— will not vote 
in the next presidential election in November 
1964, the article said. Only 63.9 per cent of all 
Americans of voting age voted in 1960, one of 
the most closely fought presidential races in 
history, it said. Less than half the electorate, 
44.8 per cent, turned out two years ago for the 


congressional elections, it said, and participation 
in state and local primaries is still lower. 

Interviewed for Today’s Health in an effort to 
discover the reasons why voters do not vote were 
public officials, leaders of both the Democratic 
and Republican parties, the staff of a specially 
appointed Presidential Commission on Registra- 
tion and Voting Participation, representatives of 
nonpartisan groups such as the American Her- 
itage Foundation, League of Women Voters, 
Kiwanis and other major service club organiza- 
tions and groups. 

Both the American Heritage Foundation and 
the Presidential Commission reported that they 
found that in millions of cases of nonvoting 
neither apathy nor bad citizenship were the 
primary factors. The executive director of the 
American Heritage Foundation said “Despite 
modern communications and active party' organ- 
izations which quickly make citizens aware of 
the issue, 37 states still require one year res- 
idence in the state, one demands two years and 
12 call for six months. County and precinct re- 
quirements often are just as unreasonable. In 
Philadelphia, where our constitution was born, 
for instance, and in other cities you can lose your 
vote merely by moving across the street to a new 
precinct a month or so before election day. This 
situation, to my mind, is a national scandal.” 

Horse-and-buggy registration procedures also 
are inhibiting, the article pointed out. Most 
states restrict registration to a central office in 
each county, at designated hours, and most close 
registration from one to nine months in advance 
of the election, long before interest has reached 
its peak. 

In most states, absentee voting provisions are 
equally archaic, according to the article. This 
would not include Missouri, however. 

States which have streamlined even part of 
their election laws far exceed the national aver- 
age in voting, it was pointed out. 

“Idaho, for example, one of the most progres- 
sive states in election administration, registered 
97.4 per cent of its electorate in 1960, and got 
out 80.7 per cent of the vote— best record in the 
nation,” it said. “Washington was not far behind 
with 72.3 per cent turnout. 

“In both states, instead of requiring citizens 
to remember and find time to report to a regis- 
tration office weeks before the election, paid 
registrars seek them out and sign them up. Res- 
idence requirements are liberal, and in Idaho, 
registration continues until 9:00 p.m. on the 
Saturday before a Tuesday election." 


82 


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C. G. STAUFFACHER, M.D., Secretary 


Missouri Academy of General Practice 


The 17th annual installation of officers and 
dinner dance of the St. Louis Academy, on Sat- 
urday night, December 7, rated par excellence. 
More than 200 members, wives, friends and guests 
enjoyed an evening of relaxation, entertainment, 
good food and drink, dancing and “just visiting” 
at the Missouri Athletic Club on this memorable 
occasion. 

Dr. Lois Wyatt, retiring president, presided 
and then turned over the gavel to the incoming 
president, Dr. Charles Nester. Other officers in- 
stalled were: Dr. Barney Finkel, president-elect; 
Dr. Paul Parashak, vice president; Dr. Charles 
Ladd, secretary; Dr. Ernest Schaper, treasurer. 
Dr. Walter T. Gunn, immediate past president 
of the Missouri Academy was introduced from 
the floor and warmly congratulated on his recent 
election to the office of president-elect of the St. 
Louis Medical Society. 

On Sunday, December 15, a meeting of the 
Education Committee of the MAGP was held in 
Jefferson City. This session was primarily held 
to initiate plans for the program of the 1964 An- 
nual Scientific Assembly of the MAGP, to be 
held at the Chase Hotel in St. Louis, on Saturday 
and Sunday, October 31 and November 1. Those 
attending the committee meeting were: Drs. Kar- 
raker, Farmington, Chairman; Hamlin, Hannibal; 
Eisenmann, New Haven; Roberts, Sweet Springs; 
Stelmach, Kansas City; Wolcott, Columbia; Dr. 
Carrier, Kansas City, President of MAGP; Dr. 



Attending the committee meeting were (left to right) 
Drs. Hamlin, Eisenmann, Carrier, Roberts, Karrarker, 
Stelmach, Wolcott, Stauffacher and Allen. 


Stauffacher, Sedalia, Secretary of MAGP; Drs. 
Allen and Belden, Jefferson City, Missouri Divi- 
sion of Health, and Mr. Ray McIntyre, St. Louis. 

The committee agreed to follow the format of 
previous annual meetings; namely, the presenta- 
tion of four symposia over the two day period. 
Panel discussion will close each symposium. On 
Saturday morning, October 31, the symposium 
will be on “Allergy”; on Saturday afternoon on 
“Pediatrics.” A “General Scientific Session” will 
be held on Sunday morning, November 1. The 
concluding symposium on Sunday afternoon will 
cover current concepts in the use of hormones. 


MISSOURI STATE MEDICAL ASSOCIATION 
1 06th Annual Session 
Hotel Chase-Park Plaza, St. Louis 
March 8, 9, 10,11, 1964 


84 



ADVERTISEMENTS 


87 



Why James Wong says he’ll do anything 
to help sell U.S. Savings Bonds 


A few years ago, in a village in central China, 
the local communist bosses held kangaroo court 
and found James Wong’s father guilty of being 
a landlord. The penalty was death and confis- 
cation of all belongings. 

Among those belongings were $850 worth of 
U.S. Savings Bonds that the senior Mr. Wong 
had purchased when he was a defense worker in 
this country during the second world war. 

His son, James, of San Francisco, who was 
named beneficiary, explained the situation to 
the Treasury Department. After verifying the 
facts, they paid the full amount plus interest. 

James Wong, like many other Americans, is 
sold on the safety of U.S. Savings Bonds. But 
far more important to him is the fact that 
Savings Bonds help protect us from the kind of 
tyranny that killed his father. 



Tens of millions of Americans are building the 
strength of their country as they save for their 
own future by buying Bonds. 

Mr. Wong urges you to join them. 


Quick facts about U.S. Savings Bonds 

• You get $4 for every 
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• You can get your 
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• Your Bonds are re- 
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• You can buy Bonds 
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Help yourself while you help your country 

BUY U.S. SAVINGS BONDS 




This advertising is donated by The Advertising Council and this magazine. 






Woman’s Auxiliary 



In a recent address to the AMA House of Del- 
egates in Portland, Ore., Mrs. C. Rodney Stoltz, 
National President, spoke of the need for in- 
creased support from county medical societies 
for the activities and programs of the auxiliaries. 
Recognition and mutual respect, one for the 
other, with areas for actual cooperative work 

will mean a greater con- 
tribution by the doctor’s 
wife to her community. 
This last year when “Op- 
eration Hometown” was 
conceived, the medical 
societies were asked to 
contact the auxiliaries for 
help in waging the cam- 
paign against “Fedicare.” 
This was not done, but 
it is not too late! Since 
the hearings on the King- 
Anderson Bill were postponed, there is still time 
to send “a deluge of expression from the grass 
roots of this nation reaching Washington in such 
volume it cannot be ignored” as Dr. Annis re- 
quested recently. 

At the Fall Conference in October, the Board 
accepted a recommendation that we promote a 
better liaison between the Auxiliary and stu- 
dents’ and interns’ wives at the medical schools. 
In one of the recent publications I received, I 
noted that the members of the Denver, Colo., 
Auxiliary invite the wives to have their meetings 
in their homes. This could apply to other stu- 
dent organizations and would certainly fit our 
theme of “Serve and Communicate.” 

Throughout my year, I have been fortunate 
to have the cooperation of Dr. Kenneth Hollweg, 
President of the Missouri State Medical Associa- 
tion, whenever I requested it. Following a dis- 
cussion held during his visit to our Fall Confer- 


ence, he referred our comments to the Council 
meeting held in December. Their Council took 
the following actions affecting the Auxiliary. 
Hereafter, the Association will mail copies of the 
Missouri Medicine annual July roster direct- 
ly to the members of our Executive Board; and 
it will assist with some of the printing and mail- 
ing of stationery and our own four page roster 
in the spring. Their Council also accepted the 
recommendation that the Auxiliary Medical Ad- 
visory Council will be composed of three mem- 
bers— the immediate past president of the Mis- 
souri State Medical Association, the Chairman of 
the Council and the Councilor from the district 
of our President. This will be an excellent and in- 
formed group to advise us and we are grateful 
the proposal met with approval. 

During December, I made the last of the trips 
for the year. I enjoyed Christmas luncheons with 
Clay, Pettis, St. Louis City and Marion-Ralls- 
Shelby auxiliaries and a dinner meeting with 
Johnson County. Each of these groups have 
worked on AMAERF either included in their 
dues or as separate collections. The Marion- 
Ralls-Shelby auxiliary made an additional dona- 
tion that day in my honor. These auxiliaries have 
also collected sample drugs and other materials 
as well as money for IHA agencies adding their 
names to many of the other groups who are sup- 
porting the project this year. St. Louis City mem- 
bers have worked on TB, Diabetes, Safety and 
Polio Vaccine drives and are now getting ready 
to be Convention hostesses. 

Now that the holidays are over, plans are 
under way on the details of the Convention to be 
held at the Chase Hotel in St. Louis, March 8 
to 11. I hope to see the best turnout ever for the 
annual meeting and know you will enjoy the 
hospitality arranged by the St. Louis City Aux- 
iliary. See you in March! 



Mrs. L. S. Crispell 


88 



Volume 61, Number 2 — February, 1964 


Missouri Medicine 

JOURNAL OF THE MISSOURI STATE MEDICAL ASSOCIATION 

Copyright, 1964 by Missouri State Medical Association. All Rights Reserved. 


LOUIS L. TUREEN, M.D., and 
ROBERT M. WOOLSEY, M.D., St. Louis 


Some Psychiatric Aspects of 
Convulsive Disorders 


The emotional manifestations of epilepsy 
patients, both those of personality distur- 
bances and reactions to being afflicted with 
epilepsy are discussed. 

Dr. Tureen and Dr. Woolsey are on the 
faculty in the Section of Neurology, Depart- 
ment of Neurology and Psychiatry of St. 
Louis University School of Medicine. 


The emotional manifestations accompanying 
convulsive disorder which are commonly ob- 
served clinically represent symptoms of person- 
ality disturbances which may be either mani- 
festations of the seizures themselves or reactions 
to being afflicted with epilepsy. Of course both 
may exist simultaneously. It is our intention to 
discuss both aspects of these emotional mani- 
festations which are important in the correct 
interpretation of the symptoms and the manage- 
ment of this disorder. On the one hand, the ictal 
and interictal phenomena may represent a sig- 
nificant psychiatric disorder related to the cere- 
bral dysrhythmia; on the other, they may rep- 
resent problems of adjustment to the convulsive 
disorder arising from conflicts at an intraperson- 
al, interpersonal or social level which require 
attention in an effective plan of treatment. We 
believe that many neurologists and psychiatrists, 
as well as family physicians, are insufficiently 
concerned with these aspects of epilepsy. 


Primary psychiatric symptoms 1 representing 
manifestations of paroxysmal discharges are fre- 
quently not recognized as such, unless accom- 
panied by convulsions or a history of seizures. 
Both adults and children may exhibit such symp- 
toms. These symptoms correlate with simul- 
taneous seizure patterns observed in the electro- 
encephalograms obtained during the periods of 
abnormality. Within hours or days after the psy- 
chiatric symptoms have abated, the EEG tracing 
may revert to the interictal pattern or even to 
normal. The attacks characteristically appear 
suddenly and terminate abruptly. 

The association of psychiatric symptomatology 
with convulsive disorder is by no means new. 
John Hughlings Jackson 2 in the latter part of the 
nineteenth century, was probably the first to 
ascribe such symptoms as disturbances of con- 
sciousness, hallucinations, illusions and emotion- 
al experiences and automatisms to an epileptic 
cause. He also noted the association of such 
symptoms with organic brain disease and, on the 
basis of two autopsied cases, localized the critical 
area to the medial aspect of the temporal lobe. 
He referred to this type of seizure as “an un- 
cinate fit.” 

Further development awaited Berger’s publi- 
cation of his discovery of the human electro- 
encephalogram in 1929. In 1937 Gibbs and 
Lennox 3 reported a series of seven patients hav- 
ing symptoms similar to those described by 
Jackson associated with generalized high voltage 


91 


92 


CONVULSIVE DISORDERS— TUREEN AND WOOLSEY 


3 to 7 per second “square topped” waves in the 
electroencephalogram. Subsequent studies by 
them and other investigators revealed that the 
electroencephalographic abnormalities were pri- 
marily located in the temporal regions of the cor- 
tex. 

Because of the combination of altered con- 
sciousness, illusions and emotional experiences 
together with automatisms which constitute the 
symptoms of these seizures, Gibbs and Lennox 4 
initially suggested that they be called “psycho- 
motor seizures.” Because of the association of 
such symptoms with demonstrable pathology of 
the temporal lobes and because of the localiza- 
tion of the EEG abnormality to this area, Len- 
nox 5 later suggested that “temporal lobe epilep- 
sy” might be a better term. 

Stimulation of the cerebral cortex in conscious 
patients at craniotomy by Penfield 6 and his group 
at the Montreal Neurological Institute did much 
to further elucidate the localization of such 
symptoms to the temporal lobe. 

Temporal lobe seizures are common. They oc- 
curred in about 20 per cent of a series of 11,612 
patients with a diagnosis of convulsive disorder 
reported by Gibbs. 7 Other authors give slightly 
higher or lower figures. They are somewhat less 
common in children and probably are seen in 
about 10 per cent of all children with convulsive 
disorders. 

In this report seven illustrative cases from a 
much larger group of patients which we have 
examined are presented. 

Alterations of consciousness are an almost con- 
stant feature of these seizures and were present 
to varying degrees in all of our patients. These 
may range from a slight alteration of awareness 
of self or environment to a gross loss of contact 
with the environment and even to levels of loss 
of consciousness. Between these extremes the 
usual alteration of consciousness consists of an 
obvious confusional state in which the patient 
will not respond to visual, auditory or tactile 
stimulation. Prolonged periods of automatisms 
of varying degrees as the result of “petit mal 
status” or repetitive temporal lobe discharges 
have been reported by Schwab, 8 Vizioli 9 and 
Goldensohn and Gold. 10 

The mechanisms by which such alterations of 
consciousness are produced are not completely 
clear. Observations on patients and experimental 
work on animals have demonstrated that small 
discrete lesions of the brain produced alterations 
in levels of consciousness only when placed in 
the reticular formation of the midbrain, the hypo- 
thalamus or the medial portion of the thalamus. 


Missouri Medicine ; 
February, 1964 

In conscious patients at craniotomy, stimulation 
in the region of the amygdala most consistently 
produces disturbances of consciousness. Since the 
amygdala is known to have connections with all 
of these described areas, it seems likely that stim- 
ulation here disrupted the normal functioning of 
the reticular activating system. 

Automatisms were present in five out of seven 
of our patients. These consisted primarily of ster- 
eotyped movements such as chewing, smacking 
lips, clenching fists, fumbling clothing and rub- 
bing the chest or abdomen. They can also consist 
of more integrated activity which is still rather 
stereotyped, such as walking about, picking up 
and handling of objects or removing clothing. 
Less commonly, the patient may exhibit a high 
degree of integrated automatic behavior such as 
that reported by Jackson 11 in the case of a physi- 
cian who during an attack examined a patient, 
and making a correct diagnosis, prescribed the 
proper treatment and suffered a total amnesia 
for the entire episode. 

Licking-chewing and swallowing movements 
have been evoked by stimulation of the amyg- 
dala in both the experimental animal and in the 
conscious human patient at craniotomy. Such lip- 
smacking movements were observed in one of 
our patients in which a neoplasm involved the 
base and medial portions of the temporal lobe. 
Movements of the homolateral and contralateral 
sides of the body have been evoked by stimula- 
tion of the lateral surface of the temporal lobe, 
insula and hippocampus in the experimental 
animal. The mechanism of the more integrated 
forms of motor behavior is unknown. 

Olfactory hallucinations were noted in one of 
our patients who reported smelling the odor of 
“glue.” Similar hallucinations have been reported 
by other patients with temporal lobe lesions. The 
odor is usually unpleasant such as “something 
burning,” a “chicken coop” or an odor of “smoke.” 
Rarely the odor is pleasant such as “flowers in 
the room.” Such sensations have consistently 
been associated with structural lesions involving 
the uncus, as in our patient who had a menin- 
gioma of the middle cranial fossa. Stimulation 
of the uncus in conscious patients at craniotomy 
has produced similar sensations. 

Visual hallucinations were present in one of 
our patients in the form of seeing people in the 
room. Such hallucinations associated with tem- 
poral lobe lesions are unlike those described by 
patients with occipital lobe lesions. They are 
highly organized and are usually of some ani- 
mate object. Similar hallucinations have been 
elicited in the conscious patient at craniotomy by 


Volume 61 
Number 2 


CONVULSIVE DISORDERS— TUREEN AND WOOLSEY 


93 


stimulation of the posterior and inferior aspects 
of the lateral surface of the temoral lobe. 

Auditory and visual illusions, that is, distorted 
perceptions rather than false perceptions, are 
also reported in some patients with temporal lobe 
seizures. They were not noted in our patients. 
Such illusions are usually associated with lesions 
on the lateral aspect of the temporal lobe. 

Illusions of memory were reported by two of 
our patients, in the form of “deja-vu” like experi- 
ences. Such memory illusions have been reported 
by conscious patients when the lateral surface of 
the temporal lobe on either side was stimulated at 
craniotomy. They were most frequently obtained 
from the nondominant cerebral hemisphere. 

Emotional experiences in the form of spon- 
taneous intense feelings of fear were reported by 
two of our patients. Fear is the most commonly 
reported emotional experience in patients with 
temporal lobe convulsive disorder although feel- 
ings of depression and pleasure may also occur. 
Penfield was able to elicit experiences of fear by 
stimulation of the anterior and inferior aspects 
of the temporal lobe in the conscious patient at 
craniotomy. Williams 12 correlated the experience 
of fear with EEG foci in the anterior aspect of 
the temporal lobe, whereas feelings of pleasure 
or depression correlated with mid-temporal and 
posterior temporal foci. 

Aphasia was noted in one of our patients and 
has been reported by others with temporal lobe 
seizures. Such symptomatology bears a well- 
known consistent relationship to lesions involving 
the posterior portion of the superior temporal 
gyrus in the dominant cerebral hemisphere. 

Case Reports 

Case 1. W. W. was an 8 year old boy who for the 
six months prior to being seen had suffered from 
recurring episodes of “doing things” without any 
realization of what was going on. Twice the attacks 
occurred upon arising and he required help in dress- 
ing. At school he was noted to be confused and did 
not know his classroom. The first three attacks lasted 
all day. The fourth lasted for three hours. During 
the episodes he responded to questions but spoke 
in a disconnected manner and appeared to be in a 
daze. Sometime prior to the disturbances he would 
complain of a stomach ache. The child was ordinarily 
considered to be bright, well behaved, agreeable 
with other children and a good pupil. He had a 
normal birth and development and had not been ill 
in any way prior to this difficulty. His neurologic 
examination was negative. An electroencephalogram 
(fig. 1A) obtained during the period of abnormality 
showed a generalized slow dysrhythmia intermittent- 
ly interrupted by multilobar high voltage, spike and 
wave complexes. No normal cerebral activity was 


noted during the entire tracing. The patient was 
treated with anticonvulsants and had no further at- 
tacks of any kind. He was considered to be normal 
in every way. A repeat electroencephalogram (fig. 
IB) taken after three years of freedom from such 
episodes showed it to be within normal limits. 




B 







Fig. 1. A. The record shows a generalized slow dys- 
rhythmia with frequent synchronous multilobar spike 
and wave complexes. B. the record is within normal 
limits. 


Case 2. T. M. was a 46 year old female who was 
admitted to the medical service of St. Louis Uni- 
versity Hospital for evaluation of a gastrointestinal 
problem. While in the hospital, she became agitated, 
irritable and paranoid in her feelings toward the 
hospital staff to such a degree that her behavior 
required transfer to the psychiatric division. Her 
neurologic examination revealed her to have a mild 
nonspecific dysarthria, nystagmus on lateral gaze to 
either side and an ataxic gait. Within a few days she 
had a remarkable spontaneous remission of her neu- 
rologic and psychiatric symptoms and was dis- 
charged from the hospital. During the ensuing year 
she was admitted to the hospital eight times with 
these identical symptoms. Further questioning elicit- 
ed a history of unexplained “blackout spells” which 
had occurred during the preceding three years. The 
spells were described as lasting a matter of minutes 


94 


CONVULSIVE DISORDERS— TUREEN AND WOOLSEY 


Missouri Medicine 
February, 1964 


and being associated with some ill-defined distur- 
bance of her thought processes. The spells had oc- 
curred several times per year and were not associ- 
ated with any type of convulsive movements. On 
several of these hospital admissions the patient was 
not rousable for hours and was suspected of having 
taken excessive doses of medication, though she 
vehemently denied this. During one of these coma- 
tose episodes an electroencephalogram (fig. 2A) was 
obtained and showed a generalized slow dysrhythmia 


A 


'■-Avvw'vvM/vy^^ 











gave a history of having had one grand mal seizure 
without aura approximately every three or four years 
since childhood. The patient was well-controlled on 
anticonvulsant drugs. On January 2, 1963, he was 
admitted to the St. Louis University Hospital for 
evaluation of a sudden confusional state. His wife 
reported that similar episodes had occurred on Jan- 
uary 1 of 1961 and January 1 of 1962. The prior two 
attacks had lasted for 24 hours. On examination the 
patient initially appeared to be alert and answered 
questions well, provided no factual data were in- 
volved. He conversed with the ward personnel in 
such a way that they did not realize that he was in 
any way abnormal. He was calm and cooperative 
and greeted his physician by name though he had 
not seen him in three years. On further questioning. 


A 

» «i 

' v/% 1 — ^”\v"V''y — v^'VV'-yV* 

144} 

B 








A\V« 


Fig. 2. A. The record shows a generalized slow dys- 
rhythmia with frequent synchronous multilobar slow 
wave bursts. B. The record is within normal limits. 

with frequent multilobar high voltage synchronous 
sharp wave bursts. The patient again showed rapid 
clearing of her sensorium and an electroencephalo- 
gram (fig. 2B) obtained two days after the one men- 
tioned was essentially within normal limits. These 
episodes and the associated EEG abnormality with 
subsequent mental clearing and reversion to a normal 
EEG were repeated on several subsequent admis- 
sions. Such episodes always began with nausea and 
vomiting and sometimes lasted for as long as 10 
days. Skull x-rays, pneumoencephalogram and spinal 
fluid examination revealed no abnormalities. Anti- 
convulsant drugs decreased the frequency and se- 
verity of these episodes. 

Case 3. N. B. is a 40 year old white male who 


L. Occ — L. Trap. 

«-L_ 

/ ,, V«w4/»v > ,i ^ V a^ » , W>W > ^ , »aa^v wV a < v — ... .... i . 

»' . ... ..yW^A-VvWY^WV — ‘ 

U Oc — l. Cent* 

144 } 


Fig. 3. A. The records show a generalized slow dys- 
rhythmia with frequent synchronous multilobar sharp 
theta-delta bursts. B. The record is within normal limits. 

however, the patient was noted to have evidence of 
gross mental confusion. He was totally disoriented as 
to time and place, could not give his correct age, 
could not tell his daughter’s last name, although it 
was his own, could not solve simple arithmetic prob- 
lems, was defective in the interpretation of proverbs 
and could not abstract on the “similarities and differ- 
ences” tests. He was totally confused regarding re- 
cent events. An electroencephalogram (fig. 3A) was 


Volume 61 
Number 2 


CONVULSIVE DISORDERS— TUREEN AND WOOLSEY 


95 


obtained during the confused state and showed a 
generalized slow dysrhythmia with much paroxysmal 
multilobar high voltage, sharp, slow wave activity, 
and frequent multilobar spike and atypical spike- 
wave bursts. By the following day the patient had 
cleared completely and the repeat electroencephalo- 
gram (fig. 3B) was normal. 

Case 4. D. P. was a 75 year old male who, in the 
summer of 1962, began to have episodes consisting 
of an alteration in his state of consciousness associ- 
ated with a lack of ability to understand what was 
said to him and a transient inability to speak. When 
he could talk, he spoke in a confused manner. On 
examination by two neurologic consultants he was 
noted to have numerous episodes of one to three 
minutes’ duration which were interpreted by the 
examiners as bouts of aphasia. These were sometimes 
of sensory variety, at other times of motor variety 
and sometimes global in nature. He was also noted 
to have a mild right facial and right brachial weak- 
ness with increased deep tendon reflexes in the right 
upper extremity, loss of position and vibration sense 
in both lower extremities and absent ankle jerks 
bilaterally. An electroencephalogram (fig. 4) done 
during these episodic disturbances showed a con- 
tinuous theta-delta rhythm over the left cerebral 
hemisphere which was maximal in the left temporal- 
occipital region. The patient continued to have such 
episodes over the subsequent nine months. He was 
readmitted to the hospital in a stuporous state. A 
short time after admission he developed bilateral 
basilar pneumonia. A shock-like picture supervened 
and he expired. Postmortem examination of the brain 
was normal except for a marked atrophy of the left 







Fig. 4. The record shows a strong theta gradiant in 
the left temporal-occipital region. 

hippocampus which was about one half the size of 
the right hippocampus. Microscopic examination re- 
vealed an almost complete loss of neurones in the 
pyramidal cell layer of the hippocampus with an 
increased number of astrocytes in this area. 

Case 5. M. J. is a 58 year old female who had 
been well until three years prior to hospitalization 
when she had a “stroke” with a left hemiparesis 
from which she recovered in about two weeks. She 


had also had a history of having had an infantile 
monoparesis of the right leg the nature of which was 
indeterminate. Two weeks prior to her being seen, 
she began to have “spells” during which she would 
lose track of what she was doing, become nauseated 
and be seized by a sudden feeling of fear and dread. 
She would then experience strange forced thoughts 
consisting of recurring ideas, words and phrases, 
which crowded out her “normal” thoughts. The 


U Prort^-L. Cent. m.j. 














Fig. 5. The record shows a generalized high voltage 
sharp pattern with a strong right-sided emphasis which 
is maximal in the temporal and occipital areas. 


attacks lasted from minutes to an entire day. The 
episodes were preceded by a tingling sensation in the 
left hand and face. An electroencephalogram (fig. 5) 
showed a generalized slow dysrhythmia with many 
positive, negative and diphasic sharp waves and with, 
an abortive spike wave activity with a strong emphasis 
of the abnormality in the right temporal region. The 
patient was treated with dilantin and phenobarbital 
and subsequently noted a decrease in the frequency 
of her seizures which were no longer present six 
months after the beginning of treatment. In the sub- 
sequent five years the patient has experienced re- 
peated periods of her aura of fear and anxiety but 
the remainder of the seizure has failed to appear. 

Case 6. C. M. was a 43 year old white female who 
had been mildly retarded since birth. At the age of 
30 she began to have episodic unconsciousness dur- 
ing which she would fall but would exhibit no tonic 
or clonic movements. These periods of unconscious- 
ness lasted about three to five minutes and were 
not associated with tongue-biting or incontinence. 
During these periods she was noted by observers to 
smack her lips and to fumble with her clothing. The 
patient herself stated that just prior to the initial 
phase of her seizure she would experience visual 
hallucinations in which she would see groups of rela- 
tives or groups of strangers moving about the room. 
She also stated that she had sudden intense feelings 
of fear which would last about one minute and 
which were unrelated to the seizures or to any other 
environmental stimulus. Her neurologic examination 


96 


CONVULSIVE DISORDERS— TUREEN AND WOOLSEY 


Missouri Medicine 
February, 1964 


was normal except for the presence of a mild gait 
disturbance and bilateral limb ataxia which was felt 
to be a drug effect. An electroencephalogram (fig. 6) 
was made and showed frequent moderate to high 
voltage monorhythmic delta activity in the left ante- 
rior temporal regions which was sometimes projected 





Fig. 6. The record shows bi-temporal theta-delta 
rhythms which are more prominent on the left side. 


to the corresponding areas on the right side. Lumbar 
puncture and air contrast studies were normal. Pa- 
tient was treated with anticonvulsants but has 
proved difficult to control. 

Case 7. D. W. was a 52 year old white female who 
was well until six weeks prior to admission when she 
began to note occasional right-sided headaches. At 
about this time, while waiting for a bus, she sudden- 
ly experienced a series of events which began with 
an awareness of a strong odor of “glue.” This was 
immediately followed by a peculiar sensation of 
unreality. She was noted to make smacking move- 





Fig. 7. The record shows intermittent theta-delta ac- 
tivity in the right temporal and frontal regions. 

ments of her lips and she dropped a package she 
had been holding. The entire episode lasted about 
one minute. She had two subsequent identical epi- 
sodes which were not preceded by any olfactory hal- 
lucination during the next five weeks. She also ex- 
perienced an increase in the severity and frequency 
of her right-sided headaches. Her neurologic exam- 


ination revealed nothing pertinent to her present ill- 
ness. An electroencephalogram showed a right front- 
temporal theta-delta focus. Lumbar puncture re- 
vealed an opening pressure of 270 mm. of water 
with a protein content of 18 mgs. per cent. A right 
carotid arteriogram was done and showed elevation 
of the right middle cerebral artery without any 
significant shift of the anterior cerebral artery. 
Craniotomy revealed a “fist sized” meningioma aris- 
ing from the floor of the middle cranial fossa which 
was extracted in toto. The patient made an unevent- 
ful recovery from the operative procedure and was 
discharged. 

In several large series of patients with tem- 
poral lobe seizures, about half of the patients 
were noted to have some significant interictal 
psychiatric abnormality which ranged from overt 
psychotic reactions to psychoneuroses and per- 
sonality disorders. 

What Bradley has called secondary behavior 
disorders in epileptics represent the patients’ at- 
tempts to adapt themselves to their illness. When 
there is sufficient brain damage, one sees symp- 
toms commonly referred to as characteristic of 
“the epileptic personality ": restlessness and over- 
activity, surliness, irritability 7 , rapid mood chang- 
es, hypochondriasis, narrowed fields of interest, 
perseverative thinking and behavior, obsessive- 
compulsive traits, ritualisms, egocentricitv and 
paranoid reactions. Thinking in these patients 
has been described as “slow and sticky,” imag- 
ination is impoverished, adaptability 7 poor. There 
is impairment of their ability to abstract. These 
symptoms may be found in patients with brain 
damage, regardless of cause, and are not neces- 
sarily related to epilepsy per se. Since they are 
apt to be seen in epileptic colonies and in severe- 
ly affected epileptics, their identification with the 
disease epilepsy is not surprising. How r ever, 
many epileptic persons are free from such symp- 
toms and possess normal or superior intelligence 
and ability 7 . There may be no evidence of “or- 
ganicity” in their personality or behavior. Even 
in these patients, how r ever, there are personality 
disturbances occurring with sufficient frequency 
to merit further inquiry. We have examined a 
group of patients to evaluate these symptoms. 

Ten young adults and 16 preadolescent epi- 
leptic children w 7 ere included in this study. 13, 14 
Factors of drug overdosage and of organic brain 
symptoms were taken into consideration in an- 
alyzing the data. Careful neurologic, psychiatric 
and social service evaluations were made. Elec- 
troencephalograms in each instance demonstrat- 
ed paroxysmal disorder. Analyses of the data in 
these patients failed to demonstrate the existence 


Volume 61 
Number 2 


CONVULSIVE DISORDERS— TUREEN AND WOOLSEY 


97 


of a basic type of personality structure which 
could be regarded as peculiarly epileptic. From 
psychologic studies alone, without supporting 
history or EEG data, none of these patients could 
be identified as epileptic. Some showed mild de- 
grees of “organicity”; the range of intellectual 
levels varied widely and there were wide ranges 
of responses to external stimuli. It was observed, 
in the study of the young adults, that some fea- 
tures were common to them all. There was a uni- 
form rebellion against the illness of convulsive 
disorder, which represented a serious stress to 
them. Their response to this stress called for a 
variety of defense mechanisms, ranging from 
fear to denial. In general they required strenuous 
efforts for successful adjustment, intensifying the 
more normal mechanisms of withdrawal and 
rationalization and the more primitive ones of 
regression or fixation. There were feelings of be- 
ing different, defective and rejected, with result- 
ant anxiety, isolation, passivity and introjection. 
They became hostile to their environment. 

The younger children demonstrated environ- 
mental responses consistent with the develop- 
ment of character of the older patients. These 
children are faced with a need to control their 
handicap and the psychologic challenges aris- 
ing from it. The immediate environment, fam- 
ily and playmates, react to the behavior and 
personality of these children, further pressuring 
them. Four categories of pressures and anxieties 
seemed to be present: ( 1 ) parental responsibility 
for the care of the patient; (2) the spectacular 
manifestations of the illness, its possible heredi- 
tary stigma, and age-old prejudices about epilep- 
sy; (3) reactions to the child’s frequently diffi- 
cult and aggressive personality; (4) stresses at 
school and later at work, where limitations in 
activities and learning presented difficulties. 

In considering the reactions of parents, overt 
and covert rebellion against the “burden” was 
frequently observed. Social and financial stress 
in dealing with the illness appeared. The sick, 
abnormal and “different” child produced un- 
comfortable feelings in the parent. Treatment 
and tests were anxiety provoking, producing 
challenges to parent and child alike. Months and 
years of medication called for explanations to 
teachers, friends, camp fellows and relatives. 

Seizures are fearsome, and present threats to 
neighbors who kept their children away, thereby 
intensifying the child’s feelings of being differ- 
ent. Guilt and disgrace feelings in the parent 
lead to overprotection or overt rejection. The 
child was treated as an invalid; punishment was 


withheld for fear of precipitating seizures, pro- 
ducing in the child insecurity and depression, 
or overt acts of aggression. Parents themselves 
blamed each other for their “catastrophe”; de- 
sertion by one or the other parent might occur, 
or recriminations might be raised about poor 
heredity, mistreatment during pregnancy or the 
punishment for not wanting the child. Such pa- 
rental conflict was additional stress to the already 
heightened emotional lability in the child. 

As has already been mentioned, in common 
with other brain damaged individuals, epileptic 
children frequently show low frustration levels, 
short attention spans, little emotional control, 
restlessness and irritability. They may be agres- 
sive with toys, playmates and siblings and are 
marked by people around them as having ab- 
normal personalities. School authorities, neigh- 
bors and even police become concerned, intensi- 
fying the feelings of these children. This interest 
frequently becomes a source of pressure on the 
parent to seek professional assistance. As a re- 
sult these children may be seen for the first time 
in a neurology clinic, by a social agency or in a 
child guidance center. Many of our referrals 
were made directly by interested agencies. 

An additional problem has to do with school- 
ing, where reading difficulties, speech defects, 
varying degrees of aphasia, difficulties with ab- 
stract subjects such as arithmetic present them- 
selves. These disorders represent organic brain 
dysfunction, not mental deficiency, and must be 
treated as such. Unless the schools were pre- 
pared to provide special facilities, such chil- 
dren, not eligible for classes for retarded chil- 
dren, have been pushed along from class to 
class, without ever having learned the funda- 
mentals of the “3 Rs.” Such educational defects 
have compounded the difficulties of being epi- 
leptic. 

For the young adult epileptic, job adjustment 
may be difficult. Unless his full potential for 
work has been developed, opportunities for em- 
ployment become limited by his lack of skills. 
Dangers inherent in certain work further limit 
his employability; even when the epileptic per- 
son can safely do a job, certain prejudices and 
anxieties about workmen’s compensation insur- 
ance requirements serve as bars against employ- 
ment. Social restrictions, limitations against auto- 
mobile driving and legal obstacles contribute to 
his feelings of separateness and anger. 

In our opinion, psychotherapy in its broadest 
sense is a valuable and necessary adjunct in the 
treatment of the epileptic person. The level of 


98 


CONVULSIVE DISORDERS— TUREEN AND WOOLSEY 


Missouri Mepicime 
February, 1984 


treatment may be the kind provided by a social 
caseworker, the psychiatric team of a child guid- 
ance clinic or of the psychiatrist. We have ob- 
served the beneficial effects of counselling of 
parents, of finding an adequate foster parent, of 
play therapy for children. In older patients, vo- 
cational guidance and job training have been in- 
valuable. In selective cases intensive psycho- 
therapy has been helpful. We have observed that 
attention to the mental health of patients has 
been successful in reducing the frequency of 
seizures, even though anticonvulsant drug dos- 
age is not altered. The role of afferent impulses, 
whether somatic, visceral or psychic, in precipi- 
tating seizures has been repeatedly demonstrat- 
ed. In common with Symond’s 15 observations, 
patients have told us of their ability to inhibit 
the progression of an epileptic seizure by what 
may be considered to be ritualistic acts or 
thoughts. In essence these might be considered 
to represent afferent stimuli which have inhibi- 
tory effects. It seems that a mental hygiene pro- 
gram for epileptic patients has a beneficial effect 
in lessening convulsion producing stimuli; pos- 
sibly also, the patient in psychotherapy learns to 
use adequately some of his defense mechanism 
in inhibiting attacks. How, is of course, unknown. 

The following case is illustrative. 

Case 8. S. H. is 9 years old and the second young- 
est child of a family of five children. He has been 
diagnosed at Cardinal Glennon Hospital as suffering 
from chronic brain syndrome with convulsive dis- 
order. He also had a marked speech impediment. His 
brother and sisters were healthy. The convulsive 
attacks were under fairly good control with anticon- 
vulsive medication until the onset of his mother’s 
mental illness. His home situation had been poor 
but now became intolerable for him. 

The father has been out of the home since 1957 
when he was sentenced to the State Penitentiary for 
seven years on a charge of rape of his, then 14 
year old, step-daughter. The mother cared for the 
children with the financial help of Aid to Dependent 
Children. After the onset of her mental illness and 
eventual hospitalization, the maternal grandmother 
assumed responsibility for the patient and his sib- 
lings. The maternal grandmother always disliked 
the patient. She blamed the patient’s seizures for 
the mother’s mental illness. She was suspicious of 
him; called him all kinds of names, refused to let 
him play with other children, locked him in his 
room and could not be bothered with administering 
his anticonvulsive medication. Finally, under these 
tremendous emotional strains and without the bene- 
fits of medication, he began to convulse frequently 
and speaks more poorly. The maternal grandmother 
brought him to the hospital because of the fre- 
quency of seizures and refused to take him back. 


She was openly hostile toward and rejecting of this 
boy. 

The child had a warm, likeable personality and 
had great need for affection and understanding, and 
loving attention. He attached himself easily to any- 
one who showed him friendship. His speech im- 
pediment improved tremendously with speech ther- 
apy. There had never been a school problem. 

With the help of a child placing agency, a foster 
home was found, with parents who were able to 
give him not only good physical care but also to 
meet his emotional hunger for love. His epileptic- 
seizures came well under control. His speech impedi- 
ment cleared up without further speech therapy. He 
has been happy in his foster home and at school 
during the last three years. 

Summary and Conclusions 

Primary psychiatric symptoms in epileptic per- 
sons represent ictal phenomena. Recognition of 
this feature of convulsive disorder, correlated 
with identifying features in the electroencephalo- 
gram, permits the institution of appropriate 
chemotherapeutic measures. 

Secondary psychiatric behavior disorders in 
epileptic persons can occur interictally. They 
are distinguished from behavior characteristic 
of organic brain syndromes, which are not spe- 
cific for epileptics. Rather, they refer to the re- 
sponses of the patient to being an epileptic and 
his frequently inadequate struggle with an en- 
vironment hostile to his illness. For such patients, 
the institution of psychiatrically oriented treat- 
ment programs has proven to be exceedingly 
beneficial. 


Bibliography 

1. Bradley, C. : Behavior Disorders in Epileptic Children. 

J.A.M.A. 146 :436, 1951. 

2. Jackson, J. H. : On the Anatomical, Physiological and Path- 
ological Investigation of Epilepsies, in Taylor, J., ed ; , Selected 
Writings of John Hughlings Jackson, Vol. I. on Epilepsy and 
Epileptiform Convulsions, London, Hodder and Stoughton. 1931, 
pp. 119-134. 

3. Gibbs, F. ; Gibbs, E., and Lennox. W. : The Likeness of 
the Cortical Dysrhythmias of Schizophrenia and Psychomotor 
Epilepsy. Am. J. Psychiat. 95 :255-269, 1938. 

4. Gibbs. F. ; Gibbs, E., and Lennox, W. : Epilepsy : A Parox- 
ysmal Cerebral Dysrhythmia, Brain 60 :377-388, 1937. 

5. Lennox, W. : Phenomena and Correlates of the Psycho- 
motor Triad, Neurol. 1 :357-371, 1951. 

6. Penfield, W., and Jasper, H. : Epilepsy and the Functional 
Anatomy of the Human Brain, Boston, Little, Brown and Com- 
pany, 1954. 

7. Gibbs, F., and Gibbs, E. : Atlas of Electroencephalography, 
Vol. 2, 2nd ed.. Addison- Wesley, 1952. p. 22. 

8. Schwah. Robert S. : A Case of Status E Ilepticus in Petit 
Mai, EEG Clin. Neurophvsiol. 5 :44, 1953. 

9. Vizioli, Roffoello, and Magliocco, Ennio Bruno: A Case of 
Prolonged Petit Mai Seizures, EEG Clin. Neurophysiol. 5 :439. 
1953. 

10. Goldensohn, Eli, and Gold, Arnold P. : Prolonged Be- 

havioral Disturbances as Ictal Phenomena. Neurol. 10:1. 1960. 

11. Jackson, John Hughlings, and Colman, W. : Case of Epi- 
lepsy With Tasting Movements and “Dreamy State.” Brain 29: 
580-590. 

12. Williams. Dennis : The Structure of Emotions Reflected in 
Epileptic Experience, Brain 79:29-67, 1956. 

13. Clower, C. G., and Tureen, Louis L. : Unpublished Obser- 
vations. 

14. Tureen. Louis L. ; O’Connell, E. J., and Hynes. Inge: Be- 
havior Disorders in Convulsive Children, South. M. J. 54:1399 
(December) 1961. 

15. Symonds, C. : Excitation and Inhibition in Epilepsy. Brain 
82 :133. 1959. 


PAUL O. HAGEMANN, M.D.; BILLY BEN BAUMANN, M.D., 

and L. S. N. WALSH, M.D., St. Louis 


Fat Embolization: 

A Postoperative Complication 


Although Warthin in 1913 1 expressed the opin- 
ion that fat embolization was the commonest 
cause of death following fractures, there remains 
considerable difference of opinion as to the mode 
of formation, frequency and significance of fat 
emboli. 

In recent years Peltier 2, 3> 4 has written ex- 
tensively in support of the “mechanical” origin 
of fat emboli. In his opinion, trauma to bone 
causes fat and often clumps of marrow cells to 
enter the venous system. Rappaport 3 reviewed 
200 fatal fracture cases and found bone marrow 
emboli in 6 per cent. Bergentz 6 and others 7, 8 
have written in detail regarding the intravascular 
origin of fat emboli due to metabolic changes 
induced by trauma or disease states. In such in- 
stances bone marrow emboli are not seen. 

The other major area of confusion results from 
failure to distinguish between symptomatic and 
asymptomatic fat embolization, the former being 
much less common. 9-12 

The case to be presented is an example of the 
mechanical type of fat embolization. It was 
symptomatic and constituted the major cause of 
death. 

Case Report 

M. A., a 26 year-old white female, was admitted 
to St. Luke’s Hospital with the chief complaint of 
inability to walk due to flexion deformities of the 
knees. 

At age 18, the patient first experienced pain in 
the hips, knees, ankles and feet. At age 19, a diag- 
nosis of rheumatoid arthritis was made and predni- 
sone therapy was instituted. During the ensuing 
years, treatment with prednisone, gold, phenylbuta- 
zone and antimalarial compounds failed to produce 
significant regression of the rheumatoid process. By 
age 20, bilateral flexion contractures of the knees 
had impaired the patient’s ability to walk, although 
hips, ankles and toes retained near normal range of 
motion. By age 26, ambulation was virtually impos- 
sible. Five months before admission a normal infant 
was delivered by caesarean section. 

When the patient was admitted to the hospital, 
the facies was mildly cushingoid and the trunk was 
moderately obese with relatively slender extremities. 
The blood pressure was 120/80 mm. Hg., tempera- 


ture 37 C., pulse rate 90 per minute and regular, 
and respirations were 24 per minute. The chest was 
clear. The heart was not enlarged and there were 
no murmurs. The spleen was easily palpable. The 
extremities showed obvious rheumatoid arthritic 
changes involving the hands, wrists and shoulders 


A report of a case of fatal fat emboliza- 
tion following surgery is presented. 

Dr. Hagemann was formerly Chief of 
Medicine, St. Luke’s Hospital, and is Assist- 
ant Professor of Medicine, Washington Uni- 
versity School of Medicine. 

Dr. Baumann is an intern at St. Luke’s 
Hospital and Dr. Walsh is pathologist at 
St. Luke’s Hospital. 


and severe changes involving both knees. The knees 
could not be extended beyond 90 degrees. The feet 
and ankles showed minimal arthritic involvement. 
Neurologic examination was not notable. 

The hemogram and urinalysis were normal. The 
VDRL was nonreactive. The latex flocculation test 
was reactive. The uncorrected erythrocyte sedimen- 
tation rate was 35 mm. /hr. The total serum protein 
was 6.8 gm. per cent with 4.0 gm. per cent of albu- 
min and 2.8 gm. per cent of globulin. The serum 
uric acid was 6.8 mg. per cent. Two examinations 
failed to reveal L.E. cells. The chest roentgenogram 
was not remarkable. Roentgenograms of the knees 
showed extreme demineralization of bone with 
roughening and erosion of the articular cortex of 
both the femur and tibia with narrowing of the 
joint space. 

After 10 days of medical and physical therapy 
had failed to produce adequate extension of the 
knees, bilateral knee arthrodesis, with 1.2 by 52 cm. 
Kiintscher intramedullary nails, was performed. Hy- 
drocortisone, 50 mg. intramuscularly, was admin- 
istered before surgery and every eight hours post- 
operatively, along with supplemental dexamethasone 
during the operation. Methohexital sodium, nitrous 
oxide and levorphanol tartrate anesthesia were em- 
ployed. The surgery was uncomplicated, the vital 
signs remaining stable throughout. During the opera- 
tion and recovery room care, 1500 cc. of whole blood 
and 1500 cc. of 5 per cent dextrose in water were 


99 


100 


FAT EMBOLISM— HAGEM ANN, BAUMANN AND WALSH 


Missouri Medicine 
February, 1964 


administered intravenously. After one hour and 40 
minutes in the recovery room, the patient was 
alert and had normal vital signs. 

Three hours postoperatively, drowsiness was ob- 
served. The pulse rate was 140 beats per minute 
and the blood pressure was 114/80 mm. Hg. A 
striking feature was chalk-white pallor in association 
with cool, dry skin. The patient’s only complaint 
was nausea. Four hours postoperatively the patient’s 
condition was unchanged. The fourth unit of whole 
blood and another liter of 5 per cent dextrose in 
water were started. Seven hours postoperatively the 
patient was semicomatose with a pulse rate of 160 
per minute, blood pressure of 130/70 mm. Hg., and 
a respiratory rate of 44 shallow breaths per minute. 
The lungs were clear to auscultation and the pupils 
were pinpoint. Both arms were moved on command 
and an extensor plantar response was elicited on the 
right. With the patient in a supine position, the 
external jugular veins were distended and the liver 
edge was palpable 2 cm. below the right costal 
margin. The pulmonic second sound was accen- 
tuated. The electrocardiogram showed sinus tachy- 
cardia and changes compatible with acute cor pul- 
monale. Methoxamine Hydrochloride, 10 mg., and 
lanatoside-C, 1.2 mg., were given intravenously and 
nasal oxygen was begun. Four hundred cc. of nor- 
mal appearing urine was obtained by catheter. At 
this time the hemoglobin was 14.3 gm. per cent. 
There was a slight clearing of the sensorium and 
the patient complained weakly of nausea. Vomiting, 
restlessness and moaning were noted. Heparin, 75 
mg. was administered intravenously. The tempera- 
ture rose to 40.2 C. and respirations increased to 60 
per minute. The pulse rate remained 140 to 160 per 
minute and the blood pressure was steady at 110/70 
mm. Hg. An additional 75 mg. of intravenous 
heparin was administered. The urine collected was 
adequate in amount with a specific gravity of 1.012. 

The situation remained unchanged until 14 hours 
postoperatively when brief periods of apnea were 
observed. The patient remained extremely restless. 
The chalk-white skin was cold and moist. Secre- 
tions began to accumulate in the bronchi and trachea 
despite frequent endotracheal suction. Sixteen hours 
postoperatively, the blood pressure was 114/70 
mm. Hg. The pulse rate was 130 per minute, and 
respirations were 24 per minute with lengthening 
periods of apnea. The hemoglobin was 15.4 gm. per 
cent. The white blood cell count was 16, 200/mm. 3., 
and the Lee- White clotting time was nine minutes. 
The blood urea nitrogen was 21 mg. per cent., serum 
electrolytes were: sodium 131 mEq. per liter, potas- 
sium 3.9 mEq. per liter and chloride 95 mEq. per 
liter. Fat was not demonstrated in the urine; how- 
ever the technic employed in the laboratory was 
open to question. 

Cyanosis and Cheyne-Stokes breathing had devel- 
oped and tracheotomy was performed. The blood 
pressure fell precipitously, respirations ceased; then 
the heart beat failed. External cardiac massage was 


to no avail and during the 21st hour after surgery 
the patient expired. 

At autopsy the body was as described with op- 
erative wounds of recent origin. From 200 to 300 
cc. of fluid were present in each pleural cavity. 
The lungs weighed 610 and 720 grams and col- 
lapsed incompletely. The cut surfaces of all lobes 
were pink in color, meaty in consistency and marked- 
ly firm with diffuse areas of atelectasis. There was 
a moderate degree of pulmonary edema with frothy 
yellow fluid oozing when slight pressure was ap- 
plied. The heart showed acute dilatation especially 




Fig. 1. Section of lung showing fat globules in small 
vessels of alveolar septa and thickening of alveolar walls. 
Sudan III stain, X 140. 


of the right auricle and ventricle. The liver was en- 
larged, weighing 2,070 grams. The kidneys appeared 
normal except for some congestion. The brain was 
edematous with flat gyri and shallow sulci and 
weighed 1,380 grams. A definite pressure collar was 
noted in the area of the foramen magnum. There 
was no gross evidence of fat in any of the organs 
examined. 

Microscopic sections of the lungs revealed fat 
globules in most small blood vessels including those 
of the alveolar walls (fig. 1). Bone marrow emboli 
were noted in some pulmonary arteries (fig. 2). 
Sections of kidney revealed many fat droplets in 
glomerular vessels and to a lesser extent in other 
small arteries. Brain sections showed numerous blood 
vessels filled with fat, which, in many instances, 
seemed to diffuse into perivascular areas (fig. 3). 
Some perivascular hemorrhages were present. 

Resume of Case Report 

This patient died 21 hours after surgery, the 
course, signs, symptoms and pathologic data all 
being characteristic of an extreme degree of fat 
embolization. There was a sudden onset of car- 
diopulmonary insufficiency three hours after sur- 
gery, associated with signs of right heart strain 


Volume 61 
Number 2 


FAT EMBOLISM— HAGEM ANN, BAUMANN AND WALSH 


101 



Fig. 2. Section of lung showing bone marrow embolus 
in small pulmonary artery. Hematoxylin and Eosin 
stain, X95. 



Fig. 3. Section of brain showing fat in small arteries 
with perivascular hemorrhage and extravasation of fat. 
Sudan III stain, X 140. 


and cerebral involvement. Findings at postmor- 
tem revealed fat embolization sufficient to impair 
pulmonary and cerebral blood flow. 

Discussion 

In review of records at St. Luke’s and Barnes 
Hospitals in St. Louis, it was of interest that not 
a single clinical diagnosis of fat embolization 
had been made in the last 10 years. During this 
period more than 19,000 orthopedic patients had 
been admitted to these hospitals. Autopsy rec- 
ords in the two institutions revealed only four 
instances of fat embolization in addition to the 
case reported here. Two of these were asso- 
ciated with fractures of long bones and two fol- 
lowed nailing of hip fractures. 

The bulk of the information on this subject 
is in literature on surgery and pathology. It 


seems appropriate to emphasize the clinical man- 
ifestations for the internist since this clinical 
picture may commonly prompt medical consul- 
tation. 

Patients most likely to develop signs and 
symptoms of fat emboli are those who have suf- 
fered trauma, especially fractures or surgical 
procedures on long bones. Delayed splinting and 
shock seem to increase the incidence of this syn- 
drome. 4 However, there is frequently a lack of 
correlation between the degree of trauma and 
the severity of the clinical manifestations of fat 
embolism. 

Characteristically, there is a latent period be- 
tween the trauma and onset of symptoms. This 
may vary from several hours to eight or 10 days, 
but most often is from 48 to 72 hours. 

Onset of clinical symptoms is heralded by 
tachypnea, tachycardia, pallor, fever and signs 
of acute right heart strain. Neurologic manifesta- 
tions may occur simultaneously or soon there- 
after. These suggest diffuse brain involvement 
with apathy, stupor or coma, along with pyram- 
idal and extra pyramidal tract signs. 10, 13-17 
Later, petechial hemorrhages are common, es- 
pecially about the head and neck. Funduscopic 
changes are rare but are quite characteristic 
when seen. Fat will not be apparent in the ves- 
sels, but a cherry red spot at or near the macula 
with surrounding retinal edema, hemorrhages 
and white exudates may be seen in the rare 
case. 18, 19 The combination of cardiopulmonary 
and neurologic signs is characteristic of the clin- 
ical syndrome of fat embolization. 

Terminal manifestations include pulmonary 
edema and shock, the signs of which are strik- 
ingly absent earlier. 4, 16 

Laboratory aids in the diagnosis of fat em- 
bolization are helpful but nonspecific. Chest 
roentgenograms reveal somewhat floccular opaci- 
ties bilaterally in perihilar and basilar distrubu- 
tion not unlike those seen in pulmonary ede- 
ma. 20-22 Demonstration of fat in the sputum is 
nondiagnostic in that 80 per cent of specimens 
from control subjects contain some fat. 23, 24 Fat 
is present in the urine of 12 per cent of healthy 
subjects and in 52 per cent of traumatized pa- 
tients. 23, 25 Lipuria is commonly seen in trauma- 
tized patients who show no clinical evidence of 
fat embolization. 23, 25, 26 Serum lipase eleva- 
tion 9, 27 is reported to occur early and the serum 
lipase determination may prove to be a worth- 
while confirmatory test. Serum lipid levels show 
no direct relation to the severity of symptoms.*' " 
Several observers have demonstrated larger than 


102 


FAT EMBOLISM— HAGEM ANN, BAUMANN AND WALSH 


Missouri Medicine 
February; 1964 


normal globules of fat in the blood stream (7 to 
15 micra ) following trauma. 6, 9 Electrocardio- 
graphic signs of acute right heart strain lend 
supporting evidence. 

The laboratory data may be nonspecific; how- 
ever, such data when combined with history, 
symptomatology and physical findings should 
afford a secure diagnostic position. 

In the large majority of instances, fat emboli- 
zation is probably asymptomatic and of no clin- 
ical importance. When the clinical picture devel- 
ops with its characteristic cardiopulmonary and 
neurologic findings, the mortality varies widely 
from 5 to 75 per cent in various groups reported, 
n, is, 23, 28, 29 ^ short or absent latent period is 
usually an indication of massive embolization, 
and the mortality is therefore higher. 30 The prog- 
nosis also seems to vary with the depth of 
coma. 29 Among patients recovered, the only 
residua described were neurologic. 17 

In the traumatized patient or the patient un- 
dergoing surgery on long bones, prompt and 
adequate splinting and the use of tourniquets 
respectively are important measures in reducing 
the amount of fat entering the circulation. 4 In 
the case reported, the amount of trauma attend- 
ant to the introduction of two intramedullary 
nails may well be considered excessive for one 
operative procedure. Peltier and Kiintscher have 
advised against the use of intramedullary nails' 
because of the amount of bone marrow which 
is disrupted with this technic. 2, 9 

The therapy of the clinical syndrome of fat 
embolization is not well established. Digitaliza- 
tion for right heart strain seems widely accepted. 
Oxygen therapy is useful as a supportive mea- 
sure. 31 The use of heparin has been both advo- 
cated 32 and condemned. 33 Peltier 34 has some 
evidence that lipase inhibitors, e.g., ethyl alcohol, 
may be helpful. Bergentz 6 has advocated low 
viscosity dextran to improve capillary circula- 
tion. Successful use of hypothermia has been 
reported by Harnett. 35 

Summary 

A case is reported of fatal fat embolization oc- 
curring in a young woman following the intro- 
duction of two Kiintscher rods. Bilateral knee 
arthrodeses were attempted because of severe 
flexion contractures secondary to rheumatoid 
arthritis. 

The patient developed respiratory embarrass- 
ment, right heart strain and stupor three hours 
after surgery and expired 18 hours later. 

The syndrome is discussed in some detail re- 


garding pathogenesis, symptoms, signs, diag- 
nosis and therapy. Sudden onset of pulmonary 
embarrassment, right heart strain and various 
neurologic signs should alert the internist to the 
diagnosis of fat embolization in his consultations 
on the orthopedic patient. 

Acknowledgement : The authors are indebted and grateful to 
Mrs. Rozene McClelland, St. Luke’s Hospital Record Librarian, 
and Mrs. Cecelia Kiel, Barnes Hospital Record Librarian, for 
their help and cooperation. 


Bibliography 

1. Warthin, A. S. : Traumatic Lipemia and Fatty Embolism, 
Internat. Clin. Series 23 4 : 171, 1913. 

2. Peltier, L. F. : Fat Embolism Following Intramedullary 
Nailing: Report of a Fatality, Surg. 32:719, 1952. 

3. Peltier, L. F. : Fat Embolism: The Amount of Fat in Hu- 
man Long Bones, Surg. 40 :657, 1956. 

4. Peltier, L. F. : An Appraisal of the Problem of Fat Em- 
bolism, Internat. Abs. Surg. 104:313, 1957. 

6. Rappaport, H. ; Raum, M., and Harrell, J. B. : Bone Mar- 
row Embolism, Am. J. Path. 2 7 :407, 1951. 

6. Bergentz, Sven-Erik : Studies on the Genesis of Post- 

Traumatic Fat Embolism, Acta. Chir. Scand. Suppl. 2 82:1, 
1961. 

7. Johnson, S. R., and Svanborg, A.: Investigations With Re- 
gard to the Pathogenesis of So-Called Fat Embolism, Ann. Surg. 
144:145, 1956. 

8. Lehman, E. P., and Moore, R. M. : Fat Embolism, Includ- 
ing Experimental Production Without Trauma, Arch. Surg. 
14:621, 1927. 

9. Aufranc, O. E. ; Jones. W. M., and Harris, W. H. : Fat 
Emboli, J.A.M.A. 178:1187, 1961. 

10. Sevitt, S. : The Significance and Classification of Fat Em- 
bolism, Lancet 2 :825, 1960. 

11. Robb-Smith, A. H. T. : Pulmonary Fat Embolism, Lancet. 
1:135. 1941. 

12. Vance, B. M. : The Significance of Fat Embolism, Arch. 
Surg. 23 :426, 1937. 

13. Ritzman, M. : Cerebral Fat Embolism, Psych. & Neurol. 
135 :301, 1958. 

14. Winkelman, N. W. : Cerebral Fat Embolism: A Clinico- 
pathologic Study of Two Cases, Arch. Neurol. & Psych. 47 :57, 
1942. 

15. Silverstein, A.: Significance of Cerebral Fat Embolism, 
Neurol 2 ’292 1952 

16. Warren, S. : Fat Embolism, Am. J. Path. 22 :69, 1946. 

17. Schneider, R. C. : Fat Embolism : A Problem in the Dif- 
ferential Diagnosis of Craniocerebral Trauma, J. Neurosurg. 
9:1, 1952. 

18. Devoe, A. G. : Ocular Fat Embolism: A Clinical and Path- 
ological Report, Arch. Opth. 43 :857, 1950. 

19. Fritz, M. H., and Hogan, M. J. : Fat Embolization Involv- 
ing the Human Eye, Am. J. Ophth. 31:527, 1948. 

20. Maruyama, Y., and Little. J. B. : Roentgen Manifestations 
of Traumatic Pulmonary Fat Embolism, Radiol. 79:945. 1962. 

21. Scott, J. C., and Kemp, F. H. : Pulmonary Fat Embolism : 
Clinical and Radiological Observations, Lancet 1 :228, 1942. 

22. Scuderi, C. S. : Fat Embolism : A Clinical and Experimen- 
tal Study, Surg. Gynec. & Obst. 72 :732, 1941. 

23. Glas, W. W. ; Grekin, T. D., and Musselman, M. M. : Fat 
Embolism, Am. J. Surg. 85 :363, 1953. 

24. Musselman, M. M. ; Glas, W. W., and Grekin, T. D. : Fat 
Embolism, Arch. Surg. 65 :551, 1952. 

25. Morton, K. S. : Fat Embolism: Incidence of Urinary Fat 
in Trauma, Canad. M. A. J. 74:441. 1956. 

26. Adler, F. ; Peltier, L. F., and Lai, S. P. : Fat Embolism: 
The Determination of Fat in the Urine by Microscopic and 
Macroscopic Means, Surg. 47 :959, 1960. 

27. Peltier, L. F. ; Adler, F., and Lai. S. P. : Fat Embolism: 
The Significance of an Elevated Serum Lipase After Trauma to 
Bone, Am. J. Surg. 99:821, 1960. 

28. Wilson, J. V., and Salisbury, C. V.: Fat Embolism in War 
Surgery, Brit. J. Surg. 31:384, 1944. 

29. Alldred, A. J. : Fat Embolism : With a Report of Nine 
Cases, Brit. J. Surg. 41 :82, 1953. 

30. Perlo, V. P. : Case Record of the Mass. Gen. Hospital. Case 
No. 25-1962, New Eng. J. Med. 226:825, 1962. 

31. Nelson, T. G., and Bowers, W. F. : Fat Embolism : An 
Analysis of Four Fatal Cases, Arch. Surg. 72 :649, 1956. 

32. Jorpes, J. E. : Heparin, Its Chemistry, Pharmacology and 
Clinical Use, Am. J. Med. 33 :692, 1962. 

33. Glas, W. W. ; Grekin, T. D. ; Davis, H. L., and Musselman, 
M. M. : An Experimental Study of the Etiology of Fat Embolism, 
Am. J. Surg. 91:471, 1956. 

34. Adler, F., and Peltier. L. F. : Fat Embolism : Prophylactic 
Treatment With Lipase Inhibitors, Surg. Forum 12 :453, 1961. 

35. Harnett, R. W. F. ; Patterson, J. R. S. ; Lowe. K. G. : 
Stewart, I. M., and Uytman, J. P. : Treatment of Cerebral Fat 
Embolism, Lancet 2 :762, 1962. 

The reader is referred to the excellent publication of Simon 
Sevitt entitled “Fat Embolism” and published by Butterworths 
of London in 1962. 


THOMAS M. MIER, M.D., and 
RAYMOND E. PROBST, M.D., St. Louis 


The First Minute of Life: 
A Physiologic Review 


Neonatology, the study of the newborn infant, 
has assumed ever increasing importance not only 
as a result of the great strides that have been 
made in understanding of the physiologic chang- 
es that occur in the fetus at the time of birth but, 
also, because it is hoped that the application of 
that knowledge may decrease the infant mor- 


Information on the physiologic changes 
that occur in the fetus at the time of birth, 
appearing principally in journals of physi- 
ology, are reviewed. r 
Dr. Mier is in the Department of Obstet- 
rics and Gynecology of St. Louis Univer- 
sity School of Medicine. Dr. Probst is an in- 
structor in Obstetrics and Gynecology and a 
Solomon A. Weintraub fellow at St. Louis 
University School of Medicine. 


bidity and mortality in the first month of life. 
Much of this information has been reported in 
journals of physiology which are frequently not 
read by the practicing obstetrician. The present 
review of the literature was undertaken to ac- 
quaint the practicing obstetrician with informa- 
tion which, though well founded from an experi- 
mental point of view, has not been fully utilized 
in clinical practice. 

Discussion 

It is well known that rhythmic respiratory 
movements occur in utero and that the neuro- 
muscular mechanisms necessary for their occur- 
rence are present as early as the twentieth week 
of gestation. 24 The onset of respiration at birth is 
not merely a continuation of intrauterine respira- 
tion. The initial respiratory effort, the primitive 
gasp, frequently occurs within a few seconds 
after the delivery of the head and it is an ex- 
plosive inspiratory effort. Respiration is controlled 
by a collection of nerve cells in the brain stem 
known as the respiratory center. These cells are 
not confined to a circumscribed area or nucleus 
but are distributed throughout the brain stem. 13 
They are located at different levels in the for- 
matio reticularis. The primitive gasp is initiated 


by the apneustic or inspiratory center located at 
the level of the striae aecousticae. It is the func- 
tion of the pneumotaxic center situated in the 
upper part of the pons, through its inhibitory 
influence, to convert the apneustic movements 
into normal respiration. 

Peripheral chemoreceptors may also play an 
essential role in the initiation of respiration. At 
birth anoxia not only fails to stimulate respira- 
tion but it may inhibit the onset of respiration 
by further depressing the respiratory center. 
Because of this, the active peripheral chemore- 
ceptors may be unable to elicit a response. In 
the initial respiratory movement of the newborn 
infant two forces need be overcome. One is the 
elastic resistance of the lungs; the other is the 
surface tension of the alveolar and bronchiolar 
walls. 24 Lungs removed from stillborn fetuses 
require up to 35 cm. of water pressure for ex- 
pansion. From surface tension alone the resis- 
tance to the first breath is equal to 10 cm. of 
water. Another factor that may influence ex- 
pansion of the alveoli is the filling of the pulmo- 
nary capillaries with blood. 47 Before the first 
breath the alveoli are crumpled sacs, and their 
capillaries contain little blood, but with the 
opening of the pulmonary circulation the capil- 
laries become filled with blood, and this to a 
minor degree contributes to their expansion. It 
can be seen that the primitive gasp is a gigantic 
effort which overcomes all the resistances in an 
organ system that is anatomically, but not yet 
functionally, developed. The function of the 
primitive gasp is to produce oxygenation of vital 
tissues, the most important of which is the brain. 
If it fails to awaken the pneumotaxic portion of 
the respiratory center, the gasps become farther 
apart and the medulla dies and this occurs be- 
fore the heart stops beating. Conversion of the 
primitive gasp or apneusis to normal rhythmic 
respiration is brought about by the inhibitory 
influence of the vagi on the apneustic center as 
well as the direct inhibitory influence of the 
pneumotaxic center on the apneustic center. 
Toward the latter part of the inspiration the al- 
veoli are stretched, thereby resulting in excita- 
tion of the afferent fibers of the pulmonary vagi 


103 


104 


FIRST MINUTE OF LIFE — MIER AND PROBST 


Missouri Medicine 
February, 1&64 


which inhibits the inspiratory activity of the ap- 
neustic center resulting in expiration. The pneu- 
motaxic center located in the pons also inhibits 
the inspiratory center. Expiration is similarly in- 
terrupted with the production of another inspira- 
tion. This reflex control, referred to as the Her- 
ring-Breuer reflex, is normally established within 
the first minute of life. In normal infants, the 
onset of respiration occurs spontaneously within 
the first minute of life. This was demonstrated 
by Higgins who reported 1,938 deliveries in 
which the onset of respiration was spontaneous 
and no resuscitation was required. These were 
all normal deliveries with no twins, prematures 
or forceps deliveries. 34 Needless to say all babies 
are not normal births and spontaneous respira- 
tion does not occur within the first minute of 
life in all instances. 

An extraordinary tolerance to anoxia is com- 
mon to all mammalian fetuses. Newborn puppies 
can live as long as 23 minutes without oxygen 
whereas adult dogs expire in three minutes un- 
der anoxic conditions. It is impossible at the 
present time to set a safe limit of time for apnea 
of the newborn infant. Newborn infants extract- 
ed by postmortem section 15 to 20 minutes after 
the death of their mothers have been revived. 14 
With longer periods of apnea at birth, abnormal 
breathing patterns and the respiratory distress 
syndrome are more prone to develop after the 
first few hours of neonatal life. 19 

Apnea of the newborn infant may be of pe- 
ripheral origin when it arises from difficulties 
in the respiratory or cardiovascular systems. It 
is of central origin when it is due to depression 
of the respiratory center. By far the most com- 
mon problem arises from the aspiration of debris. 
However, certain anomalies occur with sufficient 
frequency that one should be aware of their 
presence. The diagnosis of congenital diaphrag- 
matic hernia should be considered in every new- 
born infant with tachypnea and episodes of 
cyanosis, particularly if it persists after clearing 
of the airway. 39 X-ray of the chest easily con- 
firms the diagnosis and prompt surgery may be 
lifesaving. Esophageal atresia is less common 
but should be suspected if swallowing of saliva 
is followed by episodes of cyanosis. The pres- 
ence of hydramnios should alert one to the pos- 
sibility of such abnormalities. When a cardiac 
anomaly is present, the increased cyanosis in as- 
sociation with such activity of the baby as cry- 
ing should arouse suspicion. 

The premature infant imposes even more res- 
piratory pitfalls. Respiratory problems of the pre- 
mature arise from the state of development of 


the lung at the time of birth. In the development 
of the lung three stages can be distinguished. 
For the first four months of fetal life the lung 
may be referred to as a bronchial lung. The 
primitive tubes lined by cylindrical epithelium 
are imbedded in an avascular mesenchyme. This 
structure is incompatible with life. From four 
and one-half months of fetal life until term the 
lung is referred to as a “canalar lung.” Primitive 
air passages lined by cuboidal epithelium bud 
from the end of the bronchioles. The mesen- 
chyme becomes progressively more vascular un- 
til at about term true alveoli of the adult type 
are present. True alveoli do not develop until 
term, independent of when the baby is born. 39 

The respiratory center may be depressed by 
one of three causes: (1) Anaesthetic and anal- 
gesic agents administered to the mother during 
the course of labor 39 is, however, the least per- 
manent when skillful resuscitative measures are 
used. Without minimizing the importance of 
preventing narcosis in the newborn infant, East- 
man, et al, was unable to show its relationship 
to the etiology of cerebral palsy. 30 (2) Intra- 
uterine anoxia secondary to such conditions as 
abruptio placenta and prolapsed cord. (3) 
Cerebral edema or hemorrhage because of a long 
or difficult labor. Such operative procedures as 
version and extraction, or mid forceps, are fre- 
quently followed by varying degrees of asphyxia 
of the newborn infant. It is important to remem- 
ber that whatever the cause of the apnea, the 
longer it exists the greater is the depression of 
the respiratory center and, for that reason, mea- 
sures should be taken to counteract its presence. 
The birth canal is a dangerous passage and a 
certain amount of trauma is unavoidable. In ad- 
dition to these stated causes of fetal depression 
in the first minute of life, the baby may be suf- 
fering from shock. Shock in the newborn infant 
is due to three well defined clinical entities. 35 
The pale limp baby with respiratory distress 
may be suffering from intrauterine asphyxia, 
fetal hemorrhage or severe hemolytic disease. 
For example, knowledge that one is dealing with 
a velamentous insertion of the cord may lead to 
prompt lifesaving transfusion of the baby. 

Changes that occur in the vascular system at 
the time of birth must largely be inferred from 
animal experimentation. With the first breath, 
ventilation of the fetal lung is accompanied by 
a drop in the pulmonary arterial pressure. 4 This 
is due to the decrease in the peripheral resistance 
in the pulmonary vascular bed that occurs when 
the alveoli distend and with this their capillaries 
become an active circulation. With the decrease 


Volume 61 
Number 2 


FIRST MINUTE OF LIFE—MIER AND PROBST 


105 


in the pressure within the pulmonary artery, 
which occurs within minutes after birth, the flow 
of blood through the ductus arteriosus is re- 
versed in direction and flows from the aorta into 
the pulmonary artery. The foramen ovale, al- 
though not anatomically closed until about 12 
weeks, is functionally closed as soon as the pres- 
sure becomes greater on the left side of the heart 
than the right. 21 In experimental animals the 
musculature of the ductus arteriosus contracts 
actively at the onset of respiration because the 
chemoreceptors in its wall are stimulated by the 
increased amount of oxygenated blood flowing 
through it. Postmortem studies show the same 
thing happens in the human being. 53 Oxygen 
saturation curves show that when the blood is 
well oxygenated functional closure of the ductus 
arteriosus takes place but when there is respira- 
tory distress the musculature of the ductus arteri- 
osus fails to contract and the right to left shunt 
which occurs allows the blood to short circuit, 
the lungs thus producing a vicious cycle. 31 Fur- 
ther evidence of failure of closure of the ductus 
is the presence of a faint, transient systolic mur- 
mur which is best heard in the first 15 minutes 
of life at the third and fourth intercostal space 
on the left. This murmur is heard more often in 
babies delivered under anoxic circumstances 
than in those delivered under normal conditions. 
In one study, a murmur could be heard in 71 
per cent of babies showing signs of asphyxia as 
compared with 13 per cent of those showing no 
signs of asphyxia. 18 

Establishment of an extrauterine circulatory 
system involves separating the systemic and pul- 
monary circulation and the obliteration of the 
placental circulation. The right and left ven- 
tricular pressures are the same before breathing 
begins. In some animal experiments, clamping 
the cord produced little or no change in the 
right and left ventricular pressures. 32 There is 
a controversy as to the time vdien the cord 
should be clamped in relation to its hemody- 
namic and respiratory effects on the fetus. In 
newborn lambs if the cord is ligated before res- 
piration begins, asphyxia results as well as an 
increase in blood pressure. This is partly due to 
the asphyxia and partly because the systemic 
circulation is cut off from the low peripheral 
resistance of the placenta. With the ductus ar- 
teriosus open this high pressure is communicated 
to the pulmonary artery. 15 This sudden high 
head of pressure which is transmitted to the al- 
veolar capillaries has been incriminated by some 
investigators as a possible cause of the respira- 
tory distress syndrome. 38 The blood volume of a 


full term infant is about 400 cc., of which 100 cc. 
is in the placenta. The entire 400 cc. is propelled 
by the fetal heart. When the cord is clamped 
immediately after birth about 100 cc. of blood 
can usually be obtained from the placental end 
of the cord. This blood will flow into the infant 
if clamping is delayed until after the placenta 
is separated. 29 If the infant is deprived of this 
placental blood there is a significant reduction 
of the erythrocyte count and hemoglobin as com- 
pared to infants in which clamping w 7 as delayed. 
This alteration in the blood picture can be dem- 
onstrated in the first week of life. Failure of the 
infant to receive its placental blood may lead to 
a deficiency of iron during the first year of fife. 52 
It is obvious, therefore, that the infant’s blood 
volume is greatly influenced by the amount of 
blood transferred from the placenta at the time 
of birth. We might add though, that there are 
various opinions as to wdiether the baby actually 
needs the blood which is in the placenta at 
birth. At the time of elective cesarean section, a 
large quantity of blood is trapped in the pla- 
centa. Also, if the baby is held above the level 
of the placenta, such as on the mother’s abdo- 
men, for any period of time, it would lose addi- 
tional quantities of blood to the placenta. A com- 
mon practice at the time of delivery is stripping 
of the umbilical cord. This may be hazardous 
because the blood is forced into the baby under 
an undetermined and uncontrolled pressure and 
with undue rapidity resulting in not only cardiac 
arhythmias but transient increases in cardiac di- 
ameter as shown by x-ray. However, subsequent 
x-rays reveal that the heart size returns to nor- 
mal within a few days. 17 It is our practice to hold 
the new-born infant about 15 cm. below 7 the level 
of the placenta which is in utero, leaving the 
cord undisturbed until all pulsations have 
ceased, thus allowing the blood to flow into the 
baby under the influence of its venous pressure. 
By this procedure all the blood which is to flow 
to the fetus does so. During this short time the 
baby receives its initial evaluation according to 
the method of Virginia Apgar 3 and steps are 
taken to alleviate any depression if improvement 
is not noted by 60 to 90 seconds. 33 It is our belief 
that as the lungs expand and fill with blood, if 
the baby did not receive this placental blood, a 
hypovolemic state might ensue. 

It can be repeated that the birth canal is a 
dangerous passage causing a certain amount of 
trauma and depression which is unavoidable; 
however with the knowledge of newborn physi- 
ology, both normal and pathologic, early evalua- 


106 


FIRST MINUTE OF LIFE — MIER AND PROBST 


Missouri Medicine 
February, 1964 


tion and treatment may further reduce the de- 
clining perinatal mortality and morbidity rate. 

Summary and Conclusions 

1. A great mass of physiologic information is 
available to interpret the events of the first 
minute of life. One must utilize this information 
in the immediate neonatal care. 

2. The proper use of anesthetic and analgesic 
agents, the avoidance of trauma and the detec- 
tion of intrauterine anoxia may preserve the in- 
tegrity of the respiratory center so that the ap- 
neustic respirations that occur within 30 seconds 
of life will be followed by normal pneumotaxis 
within one minute. 

3. It seems hardly necessary to mention that 
respiratory distress may result from aspiration 
of debris. Maintain the head lower than the rest 
of the body until the respiratory passages have 
been emptied of debris. 

4. When to clamp the cord is a more con- 
traversial matter; in the full term infant, when 
there is no contraindication, the baby should be 
held about 15 cm. below the level of the placenta 
until the cord is pulseless. The venous pressure 
of the umbilical vein will determine the amount 
of blood it will receive from the placenta. 

5. It must be remembered that in the hours 
shortly after birth, the ductus arteriosus is at 
least functionally open, and that any condition 
that reduces the systemic pressure below the 
pulmonary will allow blood to pass through the 
ductus into the aorta and thus bypass the lungs. 

6. The exact relationship between the ductus 
arteriosus and the respiratory distress syndrome 
is unknown but a relationship does seem to exist. 

7. At the present time it appears that it is 
more important for the obstetrician to bear in 
mind neonatal physiology than the time honored 
mechanism of labor. 

1325 South Grand Blvd. 

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and Smith, C. A. : Studies of Respiratory Physiology in the 
Newborn Infant, J. Clin. Invest. 34:975, 1955. 

24. Cook, C. D. ; Lucey, J. F. ; Drorbaugh, J. E. ; Segal, S. ; 
Sutherland, J. M., and Smith, C. A. : Apnea and Respiratory 
Distress in the Newborn Infant, New Eng. J. Med. 254:562, 

1956. 

25. Cook, C. D. ; Sutherland, J. M. ; Segal, S. ; Cherry, R. B. ; 
Mead, J. ; Mcllroy, M. B., and Smith, C. A. : Studies of Respira- 
tory Physiology in the Newborn Infant, J. Clin. Invest. 36:440, 

1957. 

26. Cross, K. W. ; Dawes, G. S., and Mott, J. C. : Anoxia 
Oxygen Consumption and Cardiac Output in Newborn Lambs 
and Adult Sheep, J. Physiol. 146 :316, 1959. 

27. Cross, K. W. ; Klaus, M. ; Tooley, W. H., and Weiser, K. : 
The Response of the Newborn Infant in Response to Lung In- 
flation, J. Physiol. 151:551, 1960. 

28. Delafresnaye, J. F., and Oppe, T. E. : Anoxia of the New- 
born Infant, Oxford, Blackwell, 1953. 

29. DeMarsh, Q. B. ; Windle, W. F., and Alt, H. C. : Blood 
Volume of Newborn Infants in Relation to Early and Late 
Clamping of the Cord, Am. J. Dis. Child. 63 :1123, 1942. 

30. Eastman, N. J. ; Kohl, S. G. ; Maisel, J. E., and Kavaler, 
F. : The Obstetrical Background of 753 Cases of Cerebral Palsy, 
Obst. & Gynec. Survey 17 :459, 1962. 

31. Eldridge, F. L., and Holtgren, H. N. : The Physiologic 
Closure of the Ductus Arteriosus in the Newborn Infant, J. Clin. 
Invest. 34 :987, 1955. 

32. Hamilton, W. F. ; Woodbury, R. A., and Woods, E. B. : The 
Relation Between Systemic and Pulmonary Blood Pressures in 
the Fetus, Am. J. Physiol. 119:206, 1937. 

33. Hampton, L. J. : Resuscitation of the Newborn, Clin. 
Obst. & Gynec. 3 :951, 1960. 

34. Higgins, L. A.: Resuscitation of the Newborn, J. Obst. & 
Gynec. Brit. 58 :190, 1951. 

35. Hodgman, J. E. : Shock in the Newborn Infant, Clin. Obst. 
& Gynec. 4:1015, 1961. 

36. McClure, J. H., and Balagot, R. C. : Newborn Respiration, 
Obst. & Gynec. 17:243, 1961. 

37. Montgomery, T. L. : Immediate Care of the Newborn, 
Obst. & Gynec. 3 :30, 1962. 

38. Moss, A. J. ; Duffle, E. R., and Fagan, L. A. : Respiratory 
Distress Syndrome in the Newborn, J.A.M.A. 184:48, 1963. 

39. Murphy, D. R., and Owen, H. F. : Respiratory Emergencies 
in the Newborn, Am. J. Surg. 101:581, 1961. 

40. Potter, E. L. : The Study to Be Learned From a Study of 
Infant Deaths, J.A.M.A. 124:336, 1944. 

41. Prec, K. J. ; Cassels, D. E. ; Rabinowitz, M., and Moulder, 
P. V. : Cardiac Failure and Patency of the Ductus Arteriosus in 
Early Infancy, J. Pediat. 61:843, 1962. 

42. Reynolds, S. R. M. : Changes in the Circulation After 
Birth, Modern Med. 15 :83, 1957. 

43. Reynolds, S. R. M. : Regulations of the Fetal Circulation, 
Clin. Obst. & Gynec. 3 :843, 1960. 

44. Rudolph, A. M. : Pulmonary Vascular Adjustments in the 
Neonatal Period, Pediat. 28:28, 1961. 

45. Sage, E. C. : The Care of Parturient Women in Relation 
to Neonatal Mortality, J.A.M.A. 124:339, 1944. 

46. Segal, S., and Graham, B. D. : Respiratory Distress Syn- 
drome in the Newborn, Clin. Obst. & Gynec. 5 :123, 1962. 

47. Smith, C. A. : The Physiology of the Newborn Infant, 
Thomas, Springfield, 1959. 

48. Snyder, F. F., and Rosenfeld, M. : Direct Observation of 
Intrauterine Respiratory Movements of the Fetus and the Role 
of Carbon Dioxide and Oxygen in Their Regulation, Am. J. 
Physiol. 119:153, 1937. 

49. Torpin, R. : The Care of the Fetus During Labor, J.A.M.A. 
124:343, 1944. 

50. Tyson, R. M. : Immediate Care of the Newborn in Relation 
to Neonatal Mortality, J.A.M.A. 124:351, 1944. 

51. Walgren, G. ; Karlberg, P., and Lind, J. : Studies of Cir- 
culatory Adaptation Immediately After Birth, Acta Ped. 49 :843, 
1960. 

52. Wilson, E. E. ; Windle, W. F., and Alt, H. L. : Deprivation 
of Placental Blood as a Cause of Iron Deficiency in Infants, Am. 
J. Dis. Child. 62 :320, 1941. 

53. Wilson, R. R. : Postmortem Observations on Contraction 
of the Human Ductus Arteriosus. Brit. M. J. 5 0 7 4:811, 1948. 


ADVERTISEMENTS 


107 



PRO-BANTHINE* 


brand or propantheline bromide 


For Ten Years... 
the Standard Anticholinergic 

Many studies by many investigators over many 
years have established Pro-Banth!ne (propantheline 
bromide) as the standard anticholinergic in the man- 
agement of peptic ulcer and other gastrointestinal 
disorders. 

It Is Effective— Hundreds of comparative laboratory 
and clinical trials and innumerable gratified patients 
have made Pro-Banthlne (propantheline bromide) 
the most widely-prescribed medication in its class. 
It Is Selective — Its major effect is on the gastrointes- 
tinal and urogenital tracts. Secondary activity when 
noticeable seldom passes the point of temporary 
annoyance. 

It Is Dependable — Moderate doses reduce gastric 
secretion and acidity and diminish gastrointestinal 
hypermotility. The usual dosage may be safely 


doubled or tripled to suppress symptoms in patients 
with severe or refractory conditions. 

These qualities have won such wide recognition 
in standard texts on pharmacology and therapeutics 
that to prescribe Pro-Banthlne (propantheline bro- 
mide) is truly to prescribe “by the book.” 

The usual adult dosage is one tablet of 15 mg. 
with meals and two at bedtime. 

Side Effects And Cautions— Urinary hesitancy, xer- 
ostomia, mydriasis and, theoretically, a curare-like 
action may occur with Pro-Banthlne (propantheline 
bromide). It is contraindicated in patients with glau- 
coma or severe cardiac disease. 

Pro-Banthlne (propantheline bromide) is supplied 
as tablets of 15 mg. and, for parenteral use, as 
serum-type ampuls of 30 mg. 

g. d. S EARLE & co. 

CHICAGO, ILLINOIS 60680 

Research in the Service of Medicine 


ARTHUR W. NEILSON, M.D., St. Louis 

AMA Clinical Session 

Special Article 


Delegates from Missouri who served at this 
meeting were Durward G. Hall, Springfield; 
Richard H. Kiene, Kansas City; Arthur W. Neil- 
son, St. Louis, and J. Loren Washburn, Ver- 
sailles, alternate for H. E. Petersen, St. Joseph. 
In addition, Rolla B. Wray, Nevada, alternate 
delegate; President Kenneth C. Hollweg, Kan- 
sas City; Past President, Victor B. Buhler, Kan- 
sas City; Hector W. Benoit Jr., Kansas City, 
Councilor, were among those present at the 
meeting. T. R. O’Brien and Ray McIntyre of the 
staff of MSMA, Gary Schnedler, Executive Sec- 
retary of the Greene County Medical Society, 
and Hollister Smith, Executive Secretary of the 
St. Louis Medical Society, were also present. 

Richard H. Kiene introduced a resolution, 
which was approved by the delegates, requesting 
that an AMA representative appear in favor of 
H. R. 8426, which seeks to prevent physicians, 
nonprofit community blood banks or hospitals 
which do not obtain blood from any other blood 
bank, from being considered in restraint of trade 
for such acts under any law of the United States. 

Durward G. Hall was the featured speaker at 
a breakfast under the auspices of the American 
Medical Political Action Committee. Dr. Hall 
discussed the doctor and politics, relating some 
of his own experiences in Congressional cam- 
paigns and urging all doctors to take an active 
interest in the political campaigns in 1964. 

Tobacco and health, the rights and privileges 
of Negro physicians, revision of the AMA Consti- 
tution and Bylaws, voluntary health agencies 
and blood banks were among the major subjects 
acted upon by the House of Delegates at the 
American Medical Association’s Seventeenth 
Clinical Meeting. 

The AMA Layman’s Citation for Distinguished 
Service was awarded for the sixth time, and for 
the first time at a Clinical Meeting, to Mr. M. 
Lowell Edwards of Santa Ana, Calif., and 
Brightwood, Ore. Mr. Edwards, a 65 year old 
retired engineer, has designed and built artificial 
heart valves now in use in more than 2,600 per- 
sons with diseased hearts. 

The House at its opening session expressed 
deep shock at the tragic death of the late Presi- 


dent John F. Kennedy and directed that a letter 
of heartfelt sympathy be sent to Mrs. Kennedy, 
her children and the late President’s family. The 
House also pledged its support to President Lyn- 
don B. Johnson in forging national unity in the 
weeks and months ahead and offered the Asso- 
ciation’s resources, counsel and cooperation on 
matters of health. 


Proceedings of the House of Delegates 
of the clinical session of the American Med- 
ical Association held in Portland, Ore., 
December 1 to 4, 1963, are reported. Dele- 
gates from Missouri were Drs. Durward 
G. Hall, J. Loren Washburn, Richard H. 
Kiene and Arthur W. Neilson. 


Dr. Edward R. Annis, AMA president, report- 
ing on the recent House Ways and Means Com- 
mittee hearings on the King-Anderson Bill, told 
the House: 

“The combined testimony of the American 
Medical Association, the state societies and our 
allies made a far greater impact on the members 
of the committee, friend and foe alike, than at 
any other time in the history of this long and bit- 
ter conflict.’’ 

Dr. Annis also reported that under question- 
ing from Committee Chairman Wilbur Mills, 
actuaries of the Department of Health, Educa- 
tion and Welfare admitted that the program of 
tax paid hospitalization and related benefits for 
the aged proposed in the King-Anderson Bill 
would require a tax rate twice as high as they 
have previously claimed. 

Final registration at the Portland meeting 
reached a total of 7,103, including 3,144 physi- 
cians. 

Tobacco and Health 

The House approved a Board of Trustees pro- 
posal that the American Medical Association 
Education and Research Foundation undertake 
a “comprehensive program of research on tobac- 
co and health.” 

Agreeing that many gaps exist in knowledge 


108 


Volume 61 
Number 2 


AMA—NEILSON 


109 


about the relationship between smoking and 
health, the House declared that the study should 
be “devoted primarily to determining which 
significant human ailments may be caused or 
aggravated by smoking, how they may be 
caused, the particular element or elements in 
smoke that may be the causal or aggravating 
agent, and methods for the elimination of such 
agent.” 

The action called for procuring a project di- 
rector “whose experience, qualifications and in- 
tegrity will assure that such a research project 
will be conducted effectively, exhaustively and 
with complete objectivity.” 

The House agreed that the project should be 
financed by a substantial contribution from the 
American Medical Association and that contri- 
butions should be solicited from other sources— 
industry, foundations, voluntary health agencies 
and physicians. It was emphasized that contri- 
butions will be accepted only if they are given 
without restrictions. 

Subsequent to the House action, the AMA 
Board of Trustees voted to contribute $500,000 
to help finance the research program. 

Negro Physicians 

The House considered two proposals related 
to Negro physicians— a Board report on hospital 
staff privileges and a resolution concerning mem- 
bership eligibility in state and county medical 
societies. The Board report was approved, but 
the resolution was not adopted. 

In adopting the Board report, the House de- 
clared that “members of the medical staff of 
every hospital, where the admission of physi- 
cians to hospital staff privileges is subject to 
restrictive policies and practices based on race, 
be urged to study this question in the light of 
prevailing conditions with a view to taking such 
steps as they may elect to the end that all men 
and women professionally and ethically qualified 
shall be eligible for admission to hospital staff 
privileges on an equal basis, regardless of race.” 

In both its approval of the Board report and 
its rejection of the proposed resolution— which 
would have denied the rights and privileges of 
AMA membership to members of any state or 
county society which refuses membership to any 
qualified physician because of race, religion or 
place of national origin— the House reaffirmed 
1950 and 1952 policy actions on this subject and 
directed that a copy of the 1950 resolution again 
be sent to each state and county medical society. 
That resolution urged that “constituent and com- 


ponent societies having restrictive membership 
provisions based on race study this question in 
the fight of prevailing conditions with a view to 
taking such steps as they may elect to eliminate 
such restrictive provisions.” 

AMA Constitution and Bylaws 

The House approved comprehensive revisions 
and rearrangements of the Association s Consti- 
tution and Bylaws as submitted by the Council 
on Constitution and Bylaws. Among the changes 
are the following: 

1. The Annual and Clinical “Sessions” have 
been renamed the Annual and Clinical “Conven- 
tions.” 

2. The word “constituent” has been changed 
to “state.” 

3. Two types of membership have been cre- 
ated, “Active” and “Special.” Active Members 
are Regular or Service Members. Special Mem- 
bers are Associate, Affiliate and Honorary Mem- 
bers. 

4. Affiliate Membership will be available to 
American physicians engaged in medical mis- 
sionary and similar educational and philan- 
thropic labors located in possessions of the Unit- 
ed States. 

5. A quorum will be 100 of the voting mem- 
bers of the House rather than 75. 

6. A method has been established to replace 
a general officer who misses six consecutive meet- 
ings of the Board of Trustees. 

7. A method has been established for the suc- 
cessor to the President to assume the Office of 
President if the President dies, resigns or is re- 
moved from office. 

8. The Board of Trustees has been given ex- 
press authority to appoint committees. 

The House retained present provisions con- 
cerning voting on amendments to the constitu- 
tion but agreed that this matter might be con- 
sidered by the Committee to Review the Organi- 
zation of the AMA House of Delegates. 

Voluntary Health Agencies 

In approving a Board report on professional 
relationships with voluntary health agencies, the 
House declared that “the AMA maintain its pol- 
icy of neither approving nor disapproving na- 
tional voluntary health agencies.” It also agreed 
“that the AMA, through its Committee on Volun- 
tary Health Agencies, maintain its position of 
offering guidance on medical aspects of national 
voluntary health agency programs.” 

The House approved the “Principles for Medi- 


110 


AM A — NE1LSON 


Missouri Medicine 
February, 1&64 


cal Guidance to National Voluntary Health 
Agencies” which contain a new definition of a 
voluntary health agency, objectives of the Com- 
mittee on Voluntary Health Agencies and a fist 
of suggested mutual obligations between the 
AMA and the national voluntary health agencies. 
The House directed attention to the following 
two obligations: 

“There should be a mutual exchange of infor- 
mation and opinion enabling the medical pro- 
fession and the agency to understand each oth- 
er’s policy and practice.” 

“A national voluntary health agency should 
seek the advice of the medical profession when 
embarking on a national medical program.” 

In another action, the House also agreed with 
a recommendation that the Committee on Volun- 
tary Health Agencies be given the status of a 
council in the AMA organizational structure. 

Blood Banks 

The House adopted a policy statement point- 
ing out that in recent years there has been a dra- 
matic growth of blood banking facilities in the 
United States and declaring that “it is highly 
essential that the organization of new blood 
banking programs and the modification of exist- 
ing ones should have, in the interest of public 
health and safety, the approval of the county or 
district medical society and, therefore, should be 
coordinated with existing approved blood bank- 
ing facilities.” The House also approved a floor 
amendment stating that since a blood bank can 
well be considered a medical facility, the top 
authority in a blood bank should be a physician. 

Miscellaneous Actions 

In considering a wide variety of reports and 
resolutions, the House also: 

Changed the name of the Council on Scien- 
tific Assembly to the Council on Postgraduate 
Programs. 

Extended AMA Affiliate Membership to scien- 
tists in sciences allied to medicine. 

Changed the name of the Council on Medical 
Education and Hospitals to the Council on Medi- 
cal Education. 

Approved an amendment to the Bylaws which 
would permit the opening session of the House 
of Delegates to be held on Sunday afternoon or 
evening. 

Expressed gratification that the work of the 
Committee on Medicine and Religion has re- 
ceived widespread acceptance and support from 
state and county medical societies, religious 
groups and other related organizations. 


Received a report on the AMA Members Re- 
tirement Plan and urged physicians to act quick- 
ly if they are to exercise their rights under Pub- 
lic Law 87-792 during 1963. 

Requested the AMA to seek improvements in 
the format of its American Medical Directory to 
make it easier to use. 

Asked the Association staff to study the feasi- 
bility of opening the Clinical Meeting two Sun- 
days prior to Thanksgiving Day. 

Approved recommendations for criteria on 
medical examinations for driver limitation under 
certain specified conditions. 

Suggested that an appropriate committee of 
the AMA work with the United States Public 
Health Service and the industry in providing a 
type of detergent that will assure safety to the 
health of the public. 

Urged that the term “the aging” be used in- 
stead of “the aged” in all statements by the medi- 
cal profession regarding older persons. 

Approved the Guides for Medical Society 
Committees on Aging and recommended their 
wide distribution and use. 

Received a progress report from the Commis- 
sion on the Cost of Medical Care, which will 
present its final report in June 1964. 

Agreed that the Committee on Rehabilitation 
should be reconstituted and that it should in- 
clude participation of knowledgeable represen- 
tatives of all related fields of the practice of 
medicine. 

Earnestly recommended that the state medical 
societies explore the advantages of implementing 
Kerr-Mills programs in a manner which will per- 
mit the care of beneficiaries under voluntary 
health insurance programs. 

Resolved that the AMA attempt to have re- 
moved from the Kefauver-Harris Amendment 
those provisions which authorize the U. S. Food 
and Drug Administration to determine the effec- 
tiveness of drugs. 

Reaffirmed the Association’s policy of opposing 
the inclusion of self-employed physicians under 
Social Security. 

Agreed that a short form medical record may 
be used in cases of a minor nature and, in gen- 
eral, should apply to hospital stays of 48 hours 
or less. 

Approved a Board of Trustees conclusion that 
the Honors and Scholarship Program, originally 
proposed in 1960, not be implemented in the 
light of present circumstances. 

Urged all AMA members to continue to sup- 

(Continued on page 115) 


Thermonuclear Survival 


SOLOMON GARB, M.D., Columbia 


Special Medical and Nursing Civil Defense Problems 


This continues a series of articles on ther- 
monuclear survival. These include material 
previously published in the New York State 
Journal of Medicine, and are published 
with permission of that journal. 

Dr. Garb is secretary of Medical Educa- 
tion for National Defense at the University 
of Missouri. He is Associate Professor of 
Pharmacology, Department of Physiology 
and Pharmacology, at the University of Mis- 
souri School of Medicine. 

Reprints of individual articles will not be 
available but reprints of the entire series 
will be made available if there is sufficient 
demand. 


In planning their civil defense roles, the doctor 
and nurse must not only provide for the survival 
of themselves and their families, but also must be 
prepared to render practical assistance to other 
survivors. The first principle to keep firmly in 
mind is that a dead or dying doctor or nurse is 
of no value to other survivors. There is a great 
danger that doctors and nurses who survive the 
initial blast may, in their eagerness to help other 
survivors, lose their own lives needlessly. For 
every doctor or nurse who dies one may estimate 
that about 200 short-term survivors, who might 
have been saved by appropriate care in the six 
weeks following an attack, will also die. Unfor- 
tunately, some of the original plans for the use 
of doctors and nurses in a thermonuclear attack 
had basic defects which could have caused the 
needless deaths of all involved. Thus, it is vital 
to understand the defects in such plans, and to 
revise them accordingly. 

At one time, there were plans to transport doc- 
tors and nurses into the impact area, to render 
assistance to people with mechanical injuries 
from blast and flying objects. Let us consider 
these plans in the light of what is known about 
the hydrogen bomb’s effects. A 20 megaton bomb 
will produce mechanical injuries from blast, col- 
lapsing houses and flying objects over a radius 


of 10 miles (314 square miles). For a few min- 
utes after the blast, there will be no fallout; then, 
after a variable interval, depending on several 
factors, fallout will come down. One cannot 
predict exactly when the fallout will descend in 
a certain area, but it should begin within 30 min- 
utes. This so-called immediate fallout is far more 
intense than the distant fallout which extends 
over tens of thousands of square miles. Also, it 
covers the entire blast-damage area, regardless 
of wind direction. At H hour + 1, the fallout radi- 
ation level in the blast damage area will be at 
least 5,000 r. per hour. Exposure for six minutes 
or less would be lethal to persons not in shelters. 
Doctors and nurses going into such an area soon 
after an attack would certainly perish. Further- 
more, their deaths would be useless, since any 
patients exposed in that area would also receive 
a lethal dose of radiation in a few minutes. 

Therefore, it is recommended that doctors, 
nurses and other persons avoid going into any 
blast-damage area for at least two days after an 
attack, and preferably at least two weeks. The pa- 
tients in the blast-damage area probably cannot 
be saved by anyone from other areas during the 
first two days. This does not mean that they 
must be abandoned to die, however. Adequate 
civil defense preparations and training of the 
population could save the fives of many who are 
injured by blast. The first requirement is that 
there be enough community shelters in the area. 
Also, basic first-aid measures should be learned 
by most of the population. One basic first-aid 
principle will have to be changed, however: the 
principle of “splint them where they fie” is not 
applicable to a hydrogen bomb blast. The imme- 
diate fallout may come down within 10 or 20 
minutes, too short an interval for splinting and 
transporting casualties. Furthennore, the radia- 
tion intensity at 10 or 20 minutes after H hour 
may be over 20,000 r. per hour, so that a two 
minute exposure would be lethal. A first-aid 
worker who was busy splinting a casualty would 
not have enough time to get to shelter himself 
in such a situation. There is only one apparent 
solution to this problem: the injured must be 


111 


112 


THERMONUCLEAR SURVIVAL— GARB 


Missouri Medicine 
February, 1964 


carried or dragged to the nearest shelter at once 
by the nearest companions, without splinting or 
first aid. Once inside the shelter, first aid mea- 
sures may be instituted. This is certainly a severe 
solution, and undoubtedly the movement of un- 
splinted fracture patients to shelters will, in 
many instances, precipitate shock and cause oth- 
er fatal complications. Nevertheless, this pro- 
cedure offers a reasonable chance of survival to 
the fracture patient who can be moved to a 
shelter within 10 minutes. The alternate pro- 
cedure, splinting in place before movement to 
shelter, would result in close to 100 per cent 
deaths from fallout in fracture patients, as well 
as the unnecessary deaths of an equivalent num- 
ber of first aid personnel. 

The training of the entire population in basic 
first aid measures for use inside the shelter would 
certainly be of major value. In addition, there 
should be other people with more advanced first 
aid training who can assume greater responsi- 
bility, particularly since there will not be nearly 
enough doctors and nurses to go around. 

Clearly, each doctor and nurse will be faced 
with an impossible work load compared to 
peacetime standards. In many cases, a single 
physician or nurse may have to care for 200 
seriously ill patients with no other professional 
help. In such circumstances, it will be necessary 
to form a plan designed to save as many lives 
as possible. The first points to consider are the 
estimated types and proportions of casualties. 
These are discussed as percentages of the total 
incapacitated— not as percentages of the total 
population. Since some persons will suffer more 
than one type of injury, the total percentage will 
be greater than 100. It should also be noted that 
these percentages are based on the areas in- 
volved in different effects of the hydrogen bomb. 
There would be marked variations from place 
to place and the estimates are for the nation as 
a whole, based on present civil defense accom- 
plishments. Obviously, with more effective civil 
defense, the proportions would change. 

Types of Injuries 

1. Killed outright would be approximately 10 
per cent of total casualties. 

2. Multiple injuries in blast damage zone 
which would be fatal even with the best treat- 
ment would be 10 per cent. There is no reason- 
able likelihood that most of this group could 
even receive the benefit of narcotic drugs to ease 
their last moments. 

3. Persons with fractures and lacerations in 


blast damage zone not able to receive profession- 
al care because doctors and nurses are not in 
the shelter would be about 5 per cent. 

This substantial group of patients will depend 
for survival on the training and ability of laymen 
who are in the same shelter. Therefore, I recom- 
mend that a substantial proportion of the popu- 
lation be trained in advanced first-aid technics, 
so that they can give the most effective care pos- 
sible to these injured. There is a nucleus in for- 
mer military medical aid men, boy scouts and 
others. Volunteers from these groups could be 
taught enough advanced first aid to save the 
lives of many of the injured. 

4. Persons with fractures and lacerations in 
blast zone able to receive initial professional care 
because a doctor or nurse happens to be in the 
shelter would be less than 1 per cent. These 
cases will have a reasonably good chance of 
survival even without additional planning. 

5. Lacerations from broken glass in areas 10 
to 50 miles from ground zero would run 5 per 
cent. These victims are likely to swamp existing 
hospitals unless trained and taught to take a 
better course. They will have a grace period of 
30 to 90 minutes before fallout descends. If they 
go to hospitals unprepared to shelter them from 
fallout, they will probably die of fallout radi- 
ation. A better solution would be to have these 
victims go to shelters where advanced first aid 
workers can stop bleeding with pressure ban- 
dages, and give other life-saving care. After a 
period of two days to two weeks, it may be pos- 
sible to get professional surgical help to repair 
the worst cases. 

6. Burn cases with chance for survival would 
approximate 20 per cent. Most of these will be 
flash burns sustained at distances up to 25 miles 
from ground zero. The usual peacetime treat- 
ment for burns, which takes so much professional 
care— much more than major surgery— would not 
be possible. Here, too, the training of advanced 
first-aid workers in emergency treatment of 
burns, including the administration of the appro- 
priate mixture of salt and bicarbonate of soda 
orally, would save many lives. 

7. Radiation sickness would afflict 80 per cent. 
Radiation sickness is likely to be the major effect 
of a thermonuclear attack. It would be seen all 
through the nation, except in persons who get 
to a good shelter promptly and stay there for 
the proper length of time. Radiation sickness 
cases would begin soon after an attack, and in- 
crease in frequency up to about two weeks after 
the last weapon is detonated. The details of 


Volume 61 
Number 2 


THERMONUCLEAR SURVIVAL-GARB 


113 


diagnosis and treatment are described in many 
excellent publications and need not be repeated 
here. However, it is appropriate to point out that 
there are no specific anti-radiation drugs avail- 
able. The major therapeutic modality will be 
good general nursing care. This is a time-con- 
suming job. A single doctor or nurse may have 
to be responsible for hundreds of these patients. 
In such a situation, it is obviously impossible for 
a doctor or nurse to provide the care personally. 
Instead, they will have to recruit, train and direct 
others in basic technics of caring for the sick. 
Any training which can be done before the emer- 
gency will be of great value in saving lives. 

With an adequate shelter program, the num- 
ber of cases of radiation sickness would be mark- 
edly reduced. However, there would probably 
be a substantial number, even with a good shel- 
ter program. Some people may delay in getting 
to shelters, others may leave the shelter too early 
and, in some cases, shelters with minimum pro- 
tective shielding may reduce the radiation dos- 
age below the lethal level, but not below the 
level producing sickness. 

8. Secondary epidemics would afflict from 10 
to 90 per cent. Secondary epidemics have fre- 
quently accompanied wars and killed more peo- 
ple than weapons. After an attack, there will be 
multiple dangers from epidemics— even if the 
attacker does not use agents of biological war- 
fare. The usual epidemic diseases, such as ty- 
phoid and plague, already have endemic foci 
within this country. They are kept under control 
by excellent sanitary facilities. After a thermo- 
nuclear attack, many of these facilities would be 
destroyed. Unless stringent action is taken, these 
diseases could sweep the nation. First, it will be 
necessary to teach the public the need for strict 
sanitation. Secondly, regulations for purifying 
water and disposing of excreta will have to be 
established and strictly enforced, for an indefi- 
nite period after an attack. Clearly, any measures 
which could be taken in peacetime would help 
make the problem manageable. 

It would be a great help if everyone main- 
tained their immunity to smallpox and tetanus 
by periodic boosters. Special risk groups should 
also be immunized against typhoid and typhus. 

A second problem is that under the stress and 
crowding of post-attack living, microorganisms 
which have not usually been dangerous will 
overwhelm the body defenses of some persons, 
become more virulent, and start epidemics. Such 
epidemics could be even more dangerous than 
typhoid— and there are no protective vaccines 


available. An effective defense would be the 
maintenance of good general health. Nutrition 
should be adequate— and this country has the 
surplus food to make it so. 

In addition, efforts should be made to see that 
everyone has adequate rest in the post-attack 
phase. Some volunteers may try to work too 
hard and too long. Although their intentions may 
be good, they may unwittingly start, or help 
spread, an epidemic of respiratory disease by 
lowering their own resistance. Doctors, nurses 
and other responsible trained persons should in- 
sist that no one go without adequate rest. This 
applies also to the doctors and nurses themselves. 

Stockpiling Medical Supplies 

The medical and nursing professions should 
participate more actively in the planning for 
stockpiles of medical and surgical supplies for 
emergency use. In some categories, there is now 
a large stockpile, but in other cases, the stock- 
piles appear to be inadequate. 

It may be helpful to discuss a few of the items 
which are, or should be, stockpiled. The fist dis- 
cussed is by no means inclusive, but merely a 
set of examples. It is hoped that more extensive 
participation by the medical and nursing pro- 
fessions in the planning of medical stockpiles 
will result in identifying and correcting any 
other areas of imbalance. 

A. Narcotics .— The stockpile of morphine, ac- 
cording to newspaper reports, is adequate. One 
wonders how the morphine is going to get from 
the warehouses to the patients in time to do any 
good. The morphine would be needed within 
minutes to hours of an attack. It could do little 
good two or three days later. Furthermore, mor- 
phine is of no value and may be contraindicated 
in radiation sickness and the other late effects 
of a hydrogen bomb attack. 

B. Anti-emetics— The drugs which have anti- 
emetic actions could be of a tremendous value in 
managing radiation sickness. A characteristic 
feature of radiation sickness is vomiting. If the 
total radiation dose is administered within a 
short time, the vomiting may last for a few hours 
only. However, if the radiation is absorbed over 
a period of days, which would be the case with 
many victims after an attack, the vomiting tend- 
ency could also last for days. Vomiting is not 
only uncomfortable— it can be, and has been, 
fatal. Physicians are now so accustomed to the 
availability of parenteral fluids that one some- 
times tends to forget how serious persistent vom- 
iting can be in their absence. It is generally con- 


114 


THERMONUCLEAR SURVIVAL— GARB 


Missouri Medicine 
February, 1964 


sidered that a person who receives 200 r. of radi- 
ation will survive although he will vomit and 
have other symptoms. However, this is based on 
the availability of peacetime therapeutic mea- 
sures. After a thermonuclear attack, when par- 
enteral fluids are not available, a person who 
receives 200 r. of radiation and vomits for a day 
or two may die of the added effects of dehydra- 
tion and electrolyte imbalance. The anti-emetic 
drugs have been proven effective against the 
vomiting induced by radiation. They can be 
given orally or by injection. They are relatively 
inexpensive, compact, easy to store and have a 
long storage life. They also have tranquillizing 
effects. The best are probably the chlorproma- 
zine derivatives. If one had a group of several 
hundred patients with radiation sickness, begin- 
ning to vomit, it would be impossible to give 
them parenteral fluids, even if such fluids were 
available. However, the anti-emetic drugs could 
stop most of the vomiting and save the lives of 
most of the patients. Accordingly, I recommend 
that these drugs be stockpiled in large quantities. 
To the best of my knowledge, they are not being 
stockpiled as yet. 

C. Antibiotics.— The need for stockpiling anti- 
biotics seems obvious. Apparently, some stock- 
piling is being done on a small scale. However, 
there is reason to believe that the amount being 
stocked is only a small proportion of the prob- 
able need. 

D. Vaccines.— Some stockpiling of vaccines is 
taking place, but apparently it too is quite in- 
adequate. 

E. Surgical instruments.— Not only are there 
not nearly enough surgical instruments for a 
thermonuclear attack, but not even enough to 
cope with ordinary peace-time disasters. This 
was brought out graphically during the Worces- 
ter (Mass.) tornado, but apparently the lesson 
was lost. Most hospitals do not have enough 
surgical instruments to permit continuous use 
of their operating rooms in emergencies. In illus- 
tration, consider a hospital which has 10 operat- 
ing rooms, plus two rooms in the emergency 
suite which could be used for surgery. Theoreti- 
cally, it should be possible, in an emergency, to 
have 10 to 12 surgical teams, with some inter- 
nists, pediatricians and obstetricians acting as as- 
sistants. However, to run 12 major operations at 
a time, continuously and without delay, requires 
24 complete sets of surgical instruments. While 
twelve sets are in use, the other twelve are being 
washed, packed and sterilized. It is doubtful if 
a significant number of hospitals have such in- 


struments. Indeed, some preliminary inquiries 
suggest that few hospitals with 12 operating rooms 
even have 12 complete sets of instruments suit- 
able for emergency surgery or major casualties 
of a civilian or military disaster. Of the 12 oper- 
ating rooms, some are designated for surgical 
specialties such as ophthalmology, otolaryngology 
and urology and are equipped with the special- 
ized instruments only. In a disaster, there would, 
of course, be some cases requiring such special- 
ized instruments. However, the vast majority of 
cases would need the instruments used in general 
and orthopedic surgery. 

In the Worcester tornado, the surgeons en- 
countered this problem. There were not enough 
instrument sets to permit continuous use of the 
operating rooms if the instruments were cleaned 
and sterilized between operations. Accordingly, 
many surgeons resorted to the expedient of just 
washing the instruments in tap water and using 
them on the next case without sterilization. This 
probably contributed to the extremely high rate 
of postoperative wound infections. 

It is hoped that the medical and nursing pro- 
fessions will take the initiative in having this de- 
ficiency corrected at least in their own hospitals. 
Whether the additional instruments are pur- 
chased by local groups or by the federal gov- 
ernment is a matter to be considered. 

F. Blood Transfusion Apparatus.— The devel- 
opment of plastic containers for blood has sim- 
plified the problem of stockpiling. The limited 
life of bank blood is still the major obstacle to 
the storage of large amounts of whole blood. 
However, vigorous research in this area might 
provide a solution. In the meantime, blood trans- 
fusion apparatus could be stored in large 
amounts, using minimum space and at a rela- 
tively low cost. After an emergency, the unin- 
jured could then provide fresh blood for their 
injured and sick fellows. To be sure, this would 
only be of limited benefit since there would not 
be enough doctors, nurses and technologists to 
draw, match and administer all the blood need- 
ed. Nevertheless, it could save many lives. I am 
not aware of any substantial stockpiling of this 
type of apparatus as yet. 

G. Portable Hospitals.— There is a substantial 
number of portable hospitals stored on the pe- 
riphery of target areas. This stockpiling seems 
to be reasonably effective. However, some cal- 
culations suggest that the number of hospitals 
stored is only a fraction of the number which 
would be needed. Furthermore, there seem to 
be some serious omissions in the planning. A 


Volume 61 
Number 2 


THERMONUCLEAR SURVIVAL— GARB 


115 


200 bed hospital would require the services of 
more than 200 helpers. The total number of per- 
sons involved would require substantial toilet 
facilities, especially since diarrhea is a symptom 
of one stage of radiation sickness, and because of 
the need to avoid secondary epidemics. Existing 
plans call for establishing the emergency hospi- 
tals in schools, churches, armories and such. Pre- 
sumably the existing toilet facilities in these 
buildings are to be used. However, such toilets 
can only work if the water pipes to them are in- 
tact, and if there is electric power available at 
the pumping station. ( The portable gasoline 
generators used with portable hospitals would 
not be adequate. ) Since any major attack would 
probably put these services out of commission 
for a long period of time, a shortage of toilet 
facilities could cripple the operation of the emer- 
gency hospitals and spread epidemics. Accord- 
ingly, it seems advisable to include portable 
collapsible field toilets in adequate numbers 
with each emergency hospital. 

Use of Professional Personnel 
Other Than Physicians 

In the event of a thermonuclear attack, the 
number of physicians available will be far too 
small to give even reasonably adequate care to 
the injured and sick. Accordingly, plans have 
been developed to utilize other professional 
groups with some medical or paramedical back- 
ground in place of physicians. The American 
Medical Association, on April 15, 1959, presented 
a plan for emergency medical care, including 
usage of other professional groups. Unfortu- 
nately, this plan seems not to be widely known 
among the groups who will be responsible for 
implementing it. It is suggested that each physi- 
cian obtain a copy of this and any subsequent 
reports and familiarize himself with it. In addi- 
tion, the medical profession in each area should 
provide preparation and training to health per- 
sonnel other than physicians so that they may 
perform their assigned tasks effectively. The pro- 
fessions discussed in the AMA report include: 
veterinarians, dentists, nurses, technicians, tech- 
nologists, therapists, optometrists, podiatrists, 
pharmacists, social workers, psychologists, dieti- 
cians and ambulance drivers. It may be helpful 
to consider some of the additional functions rec- 
ommended for nurses, as an example. They in- 
clude: (a) first-aid, including but not limited to 
artificial respiration, emergency treatment of 


open chest wounds, relief of pain, treatment of 
shock and preparation of casualties for move- 
ment; ( b ) maintenance of patent airway, includ- 
ing intratracheal catheterization and emergency 
tracheotomy; (c) control of hemorrhage; (d) 
cleansing and treatment of wounds; (e) ban- 
daging and splinting; (f) management of psy- 
chologically disturbed; (g) management of all 
normal deliveries, and (h) operation of treat- 
ment and aid stations. 

Other functions are also fisted in the AMA re- 
port, and it is likely that subsequent revisions 
will include additional responsibilities such as 
management of burn cases. 

It should be noted that the emergency func- 
tions assigned to these other professional groups 
include major segments of current medical and 
surgical practice. They should not be confused 
with ordinary first-aid or self-help training pro- 
grams. 

The subjects discussed in this article should 
demonstrate clearly the need for greater partici- 
pation of physicians, nurses and other profes- 
sional personnel in civil defense planning. If 
these groups do not participate more actively in 
such planning, one can hardly expect to avoid 
serious errors and deficiencies in the program. 


AMA CLINICAL SESSION 

(Continued from page 110) 

port the Woman’s Auxiliary so that it can be 
successful in increasing its membership, raising 
more revenue and broadening its range of ac- 
tivities. 

Contributions and Tributes 

Merck Sharp and Dohme pharmaceutical com- 
pany made its third contribution of $100,000 to 
the student loan fund of the American Medical 
Association Education and Research Foundation. 
The AMA-ERF also received a total of almost 
$400,000 from physicians in three states for fi- 
nancial aid to medical schools. The House paid 
tribute to Mr. Thomas A. Hendricks, who is re- 
tiring on December 31, for his 20 years of AMA 
service. Dr. Annis was “commended and encour- 
aged in his great work for private enterprise and 
free American medicine.” By a rising vote of 
acclamation, the House also expressed apprecia- 
tion to Dr. Jesse D. Hamer, Phoenix, Ariz., who 
is retiring after 30 years as a delegate. 



who were the 
‘untreatables”? 


From their inception with cortisone, to the present- 
day variants of the steroid molecule, the corticoster- 
oids have presented a therapeutic paradox. The 
beneficial action against inflammation and allergy as 
well as several undesirable metabolic effects are all, 
apparently, the results of the same basic physiologic 
action. 1 

Some of these associated metabolic reactions made it 
risky or otherwise undesirable to treat with steroids 
large numbers of patients in various categories who 
would otherwise have benefited from such manage- 
ment. These “untreatables” were overweight, had 
cardiac disease, hypertension, or pulmonary fibrosis 
associated with congestive heart failure. Also in 
this category were those patients whose emotional 
symptoms were aggravated by earlier steroids. 

But the advent of ARISTOCORT® Triamcinolone in 
1958 — the result of biochemical and pharmacologic 
research which successfully stripped away many 
important undesirable hormonal effects from the 
primary anti-inflammatory action — dramatically 
changed this picture. This steroid did not overstimu- 
late the appetite, or cause the excessive weight gain 
induced by other steroids; 2 ’ 7 it proved to have one of 
the best records of any steroid for not causing edema, 
or salt-and-water retention ; 2 ’ 3 - 7 ’ 10 and the incidence 
of undesirable euphoria with this agent was remark- 
ably low. 2 - 4 - 5 - 9 - 10 What is most significant is that these 
benefits have stood the test of more than 5 years of 
widespread use. And, of course, the avoidance of 
these distressing hormonal effects benefited all pa- 
tients requiring steroids, not just those in the special 
categories, as demonstrated by wide clinical use. 


Side Effects. Since it may, under some circumstances, 
produce any of the unwanted effects common to all 
cortisone-like drugs, discrimination should always be 
exercised in administering ARISTOCORT® Triam- 
cinolone. Any of the Cushingoid effects are possible, 
as are purpura, G.I. ulceration, increased intracranial 
pressure and subcapsular cataract. Corticosteroids 
generally may mask outward signs of bacterial or 
viral infections. Catabolic effects to watch for include 
muscle weakness and osteoporosis. Weight loss may 
occur early in treatment but is usually self-limiting. 

Contraindications. While the only absolute contra- 
indications are tuberculosis and herpes simplex, there 
are some relative contraindications (peptic ulcer, 
glomerulonephritis, myasthenia gravis, osteoporosis, 
fresh intestinal anastomoses, diverticulitis, throm- 
bophlebitis, psychic disturbance, pregnancy, infec- 
tion) to weigh against expected benefits. 

While no steroid can cure a susceptible disorder, 
many patients who would otherwise be confined in a 
state of invalidism have, on ARISTOCORT® Triam- 
cinolone, been able to pursue active, useful lives. 

References: 1. Levine, R. : Rationale for the Use of Adrenal Steroids, 
Paper presented at Annual Convention, Medical Society of the State 
of New York, New York, May 13-17, 1963. 2. Hollander, J. L. : Clinical 
Use of Dexamethasone. JAMA 172:505 (Jan. 23) 1960. 3. Boland, 
E. W.: Chemically Modified Adrenocortical Steroids. JAMA 174: 835 
(Oct. 15) 1960. 4. McGavack, T. H.: The Newer Synthetic Adreno- 
cortical Steroids in Therapy. Nebraska Med. J. 4-4:377 (Aug.) 1959. 5. 
Freyberg, R. H.: Berntsen, C. A., Jr., and Heilman, L. : Further Ex- 
periences with Al, 9 Alpha Fluoro, 16 Alpha Hydroxyhydrocortisone 
(Triamcinolone) in Treatment of Patients with Rheumatoid Arthritis. 
Arthritis Rheum. J:215 (June) 1958. 6. Cahn, M. M. and Levy, E. J.: 
Triamcinolone in the Treatment of Dermatoses. Amer. Practit. 10: 993 
(June) 1959. 7. AMA Council on Drugs: New and Nonofficial Drugs. 
JAMA 169:255 (Jan. 17) 1959. 8. McGavack, T. H.; Kao, K.-Y. T.; 
Leake, D. A.; Bauer, H. G., and Berger, H. E.: Clinical Experiences 
with Triamcinolone in Elderly Men. Amer. J. Med. Sci. 236: 720 (Dec.) 
1958. 9. Fernandez-Herlihy, L.: III. Use and Abuse of Corticosteroid 
Therapy— The Structure and Biologic Activity of the Corticosteroid 
Hormones and ACTH, Med. Clin. N. Amer. 44: 509 (Mar.) 1960. 10. 
McGavack, T. H.: Triamcinolone: A Potent Anti-inflammatory Sodium 
Excreting Adrenosteroid. Clin. Med. 6: 997 (June) 1959. 


maximum steroid benefit-minimum steroid penalty 



Triamcinolone 


1 mg., 2 mg. or 4 mg. tablets 



LEDERLE LABORATORIES 


A Division of AMERICAN CYANAMID COMPANY, Pearl River, New York 

229-3 



Kenneth C. Hollweg, M.D. 


President’s 

Message 


With the hats going in the ring and the primaries 
being entered, it makes one realize that this is a big 
election year, not only for some senators and repre- 
sentatives, but from the top on down. 

Some medical issues may be settled before the 
time of the elections, but they probably will not 
and, even if they are, there will be others. 

So MMPAC and AMPAC are going to be quite 
busy organizations during this year. And we all 
know quite well that they cannot be busy protecting 
the practice of medicine and the free enterprise sys- 
tem if they do not have the financial support of the 
medical profession. 

I have made many pleas, both through this Mes- 
sage and personally, that members of the medical 
profession support these organizations and I wish to 
make this plea again. Please protect yourselves, your 
patients and the future of medicine by supporting 
MMPAC and AMPAC. 

Why not send your check for $25.00 today. This 
will cover dues in both AMPAC and MMPAC and 
it at least should be a starter. It should be sent to 
James C. Sisk, M.D., Treasurer, 111 N. 4th St., St. 
Louis 2, Mo. 



118 



EDITORIAL 


CONTROL OF POLIOMYELITIS 

That the gains in control of poliomyelitis fol- 
lowing the introduction of the Salk vaccine in 
1955 and of the Sabin oral vaccine in more recent 
years is pointed up well by statistics on the 
disease. 

In the years 1950 to 1954, an average of almost 
39,000 poliomyelitis cases a year were reported 
in the United States, the number reaching a high 
of about 58,000 in 1952. Only 910 cases of the 
disease were reported in 1962, and it appears 
that the total number for 1963 will be less than 
half the number in 1962. Currently, paralytic 
cases account for about 85 per cent of the total 
reported. 

A marked reduction has also been recorded in 
the mortality from poliomyelitis since the intro- 
duction of mass immunization programs. Deaths 
from the disease decreased from 1,043 in 1955 to 
47 in 1962. In the peak year, 1952, the number 
was 3,145. The poliomyelitis death rate fell from 
20.2 per million population in 1952 to 6.3 in 1955 
and to 0.3 in 1962. 

The incidence of poliomyelitis has reached 
such a low level in this country that not a single 
case of the disease was reported in 15 states 
and the District of Columbia during the first 44 
weeks of 1963. The West North Central and 
Mountain states reported only five cases, and 
New England only eight. Of the 362 polio- 
myelitis cases reported through November 2, 
more than 40 per cent were concentrated in two 
states, Pennsylvania with 101 and Alabama with 
51. 

Similar results have also been achieved in 
other countries where immunization programs 
were conducted on a large scale. In Canada, a 
record low of 86 paralytic cases were reported 
in 1962, equivalent to a rate of 0.5 per 100,000 
population. The rate has continued at this low 
figure in 1963. In contrast, the case rates a dec- 
ade ago were 11.8 per 100,000 in 1952 and no 
less than 28.5 in 1953. 

In England and Wales the total number of 
cases varied widely from year to year prior to 
the inauguration of the immunization program in 
1956, averaging nearly 4,000 annually in the five 


year period preceding that date. In 1962 the 
number was less than 300, and the indications 
are that the total for 1963 will be much below 
that figure. 

Most cases of poliomyelitis in the United 
States now occur among young people who have 
not been adequately immunized. As of Septem- 
ber 1962, nearly four and a half million children 
at ages 1 to 4 years— one fourth of the population 
at these ages— had received either no Salk vac- 
cine or the indequate protection afforded by one 
or two injections. In the same situation were 
about 5,100,000 children of ages 5 to 14 and 
about 2,900,000 at ages 15 to 19. Although the 
use of the oral vaccine has been increasing rapid- 
ly, there are still many millions of susceptible 
children and young adults who have not availed 
themselves of the protection it provides. 

In recent years more than one fifth of the 
paralytic cases and more than half of the deaths 
from the disease occurred among persons more 
than 15 years of age. 

Even if poliomyelitis were completely wiped 
out in the near future, there would still be the 
problem of caring for those who had been strick- 
en and left with varying degrees of residual dis- 
ability. According to a recent finding of the Na- 
tional Health Survey, it is estimated that there 
are about 120,000 cases of complete or partial 
paralysis among the survivors of a poliomyelitis 
attack. Two thirds of these are less than 45 years 
of age. 


DEATHS 

Shrout, Cecil B., M.D., Bunceton, a graduate 
of National University of St. Louis, 1914; mem- 
ber of West Central County Medical Society; 
aged 72; died November 27, 1963. 

Koenig, Karl F., M.D., St. Louis, a graduate 
of Washington University, 1931; member of St. 
Louis Medical Society; aged 64; died December 
3, 1963. 

Meisenbach, A. Edward, M.D., St. Louis, a 
graduate of Marion Sims College, 1914; mem- 
ber of St. Louis Medical Society; aged 93; died 
December 8, 1963. 


119 


News — Personal and Professional 


The medical staff of St. Mary’s Hospital, Jef- 
ferson City, recently elected Landon H. Gurnee, 
M.D., as president; Francis X. Meier, M.D., vice 
president, and William A. Cox, M.D., secretary- 
treasurer. Drs. John I. Matthews and Julian A. 
Ossman were elected to the staff’s executive com- 
mittee. 


The St. Louis Academy of General Practice in- 
stalled Charles A. Nester, M.D., St. Louis, as 
president at a dinner meeting on December 7. 


The medical staff of Peoples Hospital, St. 
Louis, recently elected William E. Allen Jr., 
M.D., as chief of staff and Leslie E. Bond, M.D., 
as vice chief. 


The Southwest Missouri Chapter of the Amer- 
ican College of Surgeons at a meeting in Spring- 
field elected Michael J. Clarke, M.D., Spring- 
field, president; Dale Alquist, M.D., Joplin, vice 
president, and F. Thomas Moseley, M.D., Spring- 
field, secretary-treasurer. 


Following the showing of films on cancer 
which were viewed by more than 2,400 women 
in Jefferson City, Drs. Harold C. Strieker, Everett 
D. Sugarbaker, Alvon C. Winegar and C. Stuart 
Exon answered questions from the audience. 


A two part history of early Callaway Doctors 
and their experiences was compiled by R. N. 
Crews, M.D., Fulton, and carried in the Fulton 
Sun-Gazette. 


Newly elected officers of the staff of St. Vin- 
cent’s Hospital, Monett, are Mary J. Newman, 
M.D., Cassville, president; A. J. Graves, M.D., 
Mount Vernon, vice president, and F. L. Ed- 
wards, M.D., Monett, secretary. 


Among speakers at a meeting in San Juan, 
Puerto Rico, in January, was Richard A. Sutter, 
M.D., St. Louis. He discussed “Medical Services 
to Multiple Small Plants.” 


The Madison Memorial Hospital staff recently 
elected C. W. Chastain, M.D., Farmington, as 
chief of staff. 


Recently elected president of the Carroll Coun- 
ty Memorial Hospital staff, Carrollton, was John 
Platz, M.D., Carrollton. E. W. Allen, M.D., Car- 
rollton, was elected vice president. 


The staff of the Cass County Memorial Hos- 
pital at Harrisonville, recently elected David S. 
Long, M.D., Harrisonville, as chief of staff. 


At a recent meeting of the Southern Medical 
Association, Ben H. Senturia, M.D., St. Louis, 
was elected chairman of the section of otolaryn- 
gology. 


Recently named president of St. John’s Hos- 
pital, Joplin, is L. H. Ferguson, M.D., Joplin. 
D. R. Patterson, M.D., was elected vice presi- 
dent. 


The St. Louis Heart Association recently elect- 
ed James P. Murphy, M.D., as president-elect. 


The Missouri Association for Mental Health 
presented a certificate to Louis H. Kohler, M.D., 
St. Louis, on December 7 for his services to men- 
tally ill persons in Missouri. 


A new member of the board of directors of 
the American Rhinologic Society is Pat A. Bar- 
elli, M.D., Kansas City. 


Acting as chairman of the committee on by- 
laws, C. A. Brashear, M.D., Mount Vernon, con- 
ducted a meeting during the interim clinical 
meeting of the American College of Chest Phy- 
sicians in Portland, Ore., recently. He also served 
as a discussant in a fireside conference on “Tu- 
berculosis: Early Diagnosis, Primary Tuberculo- 
sis, Chemoprophylaxis.” 

(Continued on page 122) 


120 



In Sprains, Strains and Muscle Spasm, ‘Soma’ Compound 

numbs the pain...not the patient 


A potent analgesic and 
a superior muscle relaxant 

1. A sprain or fracture is not a big clinical problem— 
but it does hurt. And if there is housework to do and 
kids to mind, the patient needs something to numb 
the pain. 

2. A.P.C. compounds have limited usefulness; and 
the patient can buy them without your prescription. 
Unfortunately, most of them are too mild to be effec- 
tive for sprains— and more potent products too often 
make the patient feel ‘dopey’. 

3. ‘Soma’ Compound is ideal in these cases. Since it 
contains both ‘Soma’ (carisoprodol) and acetophenet- 
idin it is both a potent analgesic and a superior mus- 
cle relaxant; it also contains caffeine to offset any 

drowsiness (“numbs the pain... not the patient”). 

' 

CSO-9193 


4. Why not try ‘Soma’ Compound? Dosage is 1 or 2 
tablets q.i.d. For more severe pain, try ‘Soma’ Com- 
pound + Codeine. Dosage: 1 or 2 tablets q.i.d. 

5. Hypersensitivity to carisoprodol may occur rarely. 
Codeine may produce addiction, nausea, vomiting, 
constipation or miosis. 


SomaCompound § 

carisoprodol 200 mg., acetophenetidin 160 mg., caffeine 32 mg. 

Soma Compound+Codeine j 

carisoprodol 200 mg., acetophenetidin 160 mg., caffeine 32 mg., 
codeine phosphate 16 mg. (Warning -may be habit forming.) 

WALLACE LABORATORIES J Cranbury, N.J. 



Ramblings of the Field Secretary 


During recent years there has been consider- 
able attention paid to the number of students ap- 
plying for entrance to medical schools, the num- 
ber admitted and the number graduating each 
year. Some statistics relating to these points of 
concern would seem to be in order. 

The total number of medical students enrolled 
in the 87 U. S. medical schools was 31,491 for 
the 1962-1963 academic year according to the 
November 16, 1963, issue of the Journal of the 
AM A. The journal further reports that this figure 
represents an increase in total enrollment of 413 
students (1.3 per cent), while the increase in 
the number of first year students was 159 (2.2 
per cent). Further, states the journal “the num- 
ber of graduates was 7,265 for the 1962-1963 
year, an increase of 96 over the previous year. 
This increase in graduates of 1.4 per cent was 
slightly less than the average increase in medical 
school graduates over the past decade of about 
2 per cent and also significantly less than the 
average annual increase of the U. S. population 
for the last decade of 1.7 per cent.” 

In additional discussion of this matter the jour- 
nal says, “The current data indicate that the de- 
crease in applicants for entering classes of med- 
ical schools which has been fairly constant since 
1949 reached its low point in the 1961-1962 year 
and is now on the upward swing. As reported 
by the Association of American Medical Colleges 
15,847 students applied for places in the first year 
class for the 1962-1963 year, an increase of 1,466 
(10 per cent) over the preceding year. Prelim- 
inary estimates indicate that the number of ap- 
plicants for the 1963-1964 classes have again in- 
creased at least 15 per cent. Primarily because 
of the increasing number of students expected to 
graduate from colleges and universities, it is 
likely that the number of applicants to medical 
schools will increase substantially during the 
next several years. 

“Since 1960, when there was ‘widespread con- 
cern because of the decreasing numbers of qual- 
ified students’ applying to medical school, there 
has been an increased activity and variety of re- 
cruitment programs in medical schools, medical 
societies and medical organizations. At that time 
only 30 schools had active programs. Now 49 


schools have formal programs. Besides the activ- 
ity of the medical schools, the American Med- 
ical Association, Association of American Med- 
ical Colleges, local medical societies and the Stu- 
dent American Medical Association, to mention 
a few, continue to conduct large-scale programs. 

“In the past two years, there has been a sharp 
upturn in the number of applicants which has 
dissipated some of the interest in recruitment. 
Two schools reported that due to the plethora of 
applicants, ‘formal recruitment was not contem- 
plated. Medicine, however, continues to compete 
with an increased number of ‘status professions’ 
for the top students. These students have in- 
timate contact with the proponents of these other 
disciplines during their college years— at a time 
when they have little or no exposure to medicine. 
Thus, in spite of increased applicant pressure, 
continued recruitment seems necessary.” 


NEWS 

(Continued from page 120) 

“A Modern Medical Program for the Small 
Plant” was the subject of a talk given by Rich- 
ard A. Sutter, M.D., St. Louis, at a recent meet- 
ing of the National Safety Council. 


Recently installed as president of the Kansas 
City Society of Ophthalmology was Williston P. 
Bunting, M.D. 


The new president of the Downtown Kiwanis 
Club, Kansas City, is James E. Tesson, M.D., 
Kansas City. 


The Student American Medical Association, at 
its 1963 annual meeting, set up a sustaining mem- 
bership of the organization. This is open to any 
physician for a fee of $10.00 annually. Physicians 
should address applications for sustaining mem- 
bership to the Student American Medical Associ- 
ation, 333 N. Michigan Ave., Chicago 1, 111. 


122 


cut Rx writing by 2/3 
in colds, flu or grippe 


Name 

Address. 


No need to write three separate prescriptions for antitussive, 
decongestant and analgesic relief of common cold, 
flu or grippe symptoms when it is therapeutically correct . . . 

economically sound. ..to specify 

ANTITUSSIVE/DECONGESTANT/ANALGESIG 

‘EMPRAZIL-C’TABLETS 

Each tablet contains: 

Codeine Phosphate* .....’ 15 mg. 

‘Sudafed’® brand Pseudoephedrine Hydrochloride. . 20 mg. 

‘Perazil’® brand Chlorcyclizine Hydrochloride 15 mg. 

Phenacetin 150 mg. 

spirin 200 mg. 

Caffeine 30 mg. 

'Warning — may be habit forming 

‘Emprazil-C’ Tablets are available on prescription only. 

Dosage: Adults and children over 12 years — 1 or 2 
tablets — 3 times daily as required. Children 6 to 12 
years — 1 tablet— 3 times daily as required. Caution: 
While pseudoephedrine is virtually without pressor 
effect in normotensive patients, it should be used 
with caution in hypertension. Also, while chlorcy- 
clizine has a low incidence of antihistaminic 
drowsiness, the usual precautions should be 
observed. Supplied: Bottles of 100 tablets. 

Also available without codeine as 
‘EMPRAZIL’® TABLETS 

Complete literature available on request from 

S Professional Services Dept. PML. 

BURROUGHS WELLCOME & CO (U.S.A.) INC. 

Tuckahoe. N. Y. 


124 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
February, 1964 


MISSOURI STATE MEDICAL ASSOCIATION 
Preliminary Program 
106th Annual Session 
Hotel Chase, St. Louis 
March 8, 9, 10, 11, 1964 


12:00 noon 
1:30 p.m. 
3:00 p.m. 
3:00 p.m. 
3:30 p.m. 
4:00 p.m. 
4:30 p.m. 
4:45 p.m. 
6:30 p.m. 


8:00 a.m. 
9:00 a.m. 


10:30 a.m. 
11:00 a.m. 


12:00 noon 
12:00 noon 
12:00 noon 


Sunday, March 8, 1964 
Registration of Delegates. Lobby floor. 

House of Delegates, Khorassan Room. 

Reference Committee meetings. 

Reports of Officers, Coach Room. 

Constitution and By-laws, Park Room. 

Miscellaneous Affairs, Paladium Room. 

Resolutions, Colonial Room. 

Necrology, English Room. 

Missouri Diabetes Society dinner meeting, Stockholm Room. 
Relationship Between Severity of Diabetes and Insulin Secretory 
Reserves, Holbrooke S. Seltzer, M.D., Dallas, Tex. 

Monday, March 9, 1964 

Registration. Lobby floor. 

Panel: What’s New, Khorassan Room. 

Moderator: Thomas F. Frawley, M.D., St. Louis. 

New Trends in Medicine: William D. Davis Jr., M.D., New 
Orleans. 

New Trends in Surgery: Thomas L. Marchioro, M.D., Denver. 
New Trends in Allergy: Charles W. Parker, M.D., St. Louis. 

New Trends in ENT: John J. Shea, M.D., Memphis, Tenn. 

Intermission to View Exhibits. 

Panel: Current Concepts in Treatment of Chronic Renal Disease, 
Khorassan Room. 

Moderator: C. Thorpe Ray, M.D., Columbia. 

Problems Involved in an Artificial Kidney Center Devoted Solely 
to Chronic Dialysis, F. K. Curtis, M.D., Seattle. 

Some Problems Involved in Human Homo-transplantation, Thomas 
L. Marchioro, M.D., Denver. 

50 Year Club Luncheon, Park Room. 

M. K. Underwood, M.D., Rolla, presiding. 

Committee on Maternal Welfare Luncheon, Regency Room. 

Speaker: Arthur L. Haskins, M.D., Baltimore, Md. 

Luncheon Fireside Conference, Colonial Room. 

Vagrant Acid Fast Organisms in Pulmonary Disease: The Physician’s 
Dilemma. 

Moderator: Karl H. Pfuetze, M.D., Hinsdale, 111. 

Panelists: 

Raymond F. Corpe, M.D., Rome, Ga. 

Ernest H. Runyon, Ph.D., Salt Lake City, LTah. 

John H. Seabury, M.D., New Orleans, La. 

Henry C. Sweany, M.D., Mount Vernon, Mo. 

Medical Session, Lido Room. 


2:00 p.m. Panel: Liver Disease. 

Moderator: Robert E. Koch, M.D., St. Louis. 


ADVERTISEMENTS 


125 


When your patient says: 




BRAND OF LOBELINE SULFATE, MRT 

help curb the smoking habit 


■ Help induce a feeling of satiety similar to 
that of tobacco because of lobeline’s phar- 
macological relationship to nicotine. 

■ Permit the patient to indulge his oral fixa- 
tion by substituting the Nikoban Pastille B 
for tobacco. 


M U tilize the anorexic effect of lobeline to help 
the patient who is driven to compulsive eat- 
ing when he discontinues smoking. 

Encourage patient cooperation through 
pleasant taste. 


Dosage and Administration: In order to obtain the maximum benefit, a Nikoban Pastille should be sucked slowly and 
taken according to the schedule below. Whenever possible a pastille should be taken after meals. 

1st week: I pastille every 1 to 2 hours for a maximum of 12 pastilles daily. 2nd week: 1 pastille every 3 hours. 3rd week: 1 
pastille every 4 hours. 4th week: 1 pastille every 4 to 6 hours. Thereafter 1 pastille may be taken at infrequent intervals 
whenever necessary. In some instances there may at first be a slight astringent burr of the tongue and throat. This will 
usually disappear as treatment with Nikoban Pastilles progresses and is no cause for concern. 

Caution: It is advisable neither to smoke nor to use a smoking deterrent during pregnancy. 

Formulation: Each Nikoban Pastille contains 0.5 mg. lobeline sulfate in a pleasant tasting spiced-cherry base. 


Availability: In packages of 50 pastilles. 


References: 1. Goodman, L. S. and Gilman. A.: The 
Pharmacological Basis of Therapeutics, New York, 
Macmillan, 1960, Ed. 2, pp. 620-622: 2. Edmunds, 
C. W.: J. Pharmacol, and Exper. Therap., 1:27, 1909: 

3. Hazard, R. and Savini, E. Gand., 92:471, 1963. 

4. Dorsey, J. L.: Ann. Int. Med.. 10:628, 1936; 5. Ras- 
mussen, K. B.: Ugeskr.laeger, 118:222, 1956; 6. Ejrup, 
B.: Sven. lak. Tid., 53:2634, 1956; 7. Jochum, K. and 
Jost, F.: Munch, med. Wchnschr., 103:618. 1961; 8. 
Jost, F. and Jochum, K.: Med. Klin., 54:1049, 1959; 
9. Smoking and Health, Summary and Report of the 
Royal College of Physicians of London on Smoking. 
New York, Pitman, 1962. 


M. R. THOMPSON, Inc., Medical Department- BB 
711 Fifth Avenue, New York, New York 10022 

Gentlemen: 

Please send me a trial supply of NIKOBAN Pastilles. 

NAME M.D. 

ADDRESS 

CITY ZONE STATE 

TYPE OF PRACTICE 


M. R. THOMPSON, INC. • NEW YORK, NEW YORK 10022 




126 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
Febbuaby, 1964 


2:00 p.m. 

2:30 p.m. 


3:00 p.m. 


3:30 p.m. 
4:00 p.m. 
5:30 p.m. 
6:30 p.m. 


6:30 p.m. 
6:30 p.m. 


Problems in Treatment of Cirrhosis, William D. Davis Jr., M.D., 
New Orleans. 

Sponsored by the Missouri Society of Internal Medicine. 

Hemochromatosis, Holbrooke S. Seltzer, M.D., Dallas, Tex. 

Sponsored by the Missouri Diabetes Society. 

Current Problems in Hepatitis, Hyman J. Zimmerman, M.D., Chica- 
go. 

Surgical Session, Khorassan Room. 

Paul F. Max, M.D., St. Louis, presiding. 

Regional Enteritis — Surgical Aspects, B. Marden Black, M.D., 
Rochester, Minn. 

Sponsored by the Missouri Surgical Society. 

The Chiari Frommel Syndrome ( Medroxyprogesterone Acetate 
Therapy), Arthur L. Haskins, M.D., Baltimore, Md. 

Sponsored by the St. Louis Gynecologic Society. 

Care of the Child With Multiple Injuries, John C. Wilson Jr., Los 
Angeles. 

Intermission to View Exhibits. 

House of Delegates. 

Reference Committee meetings. 

St. Louis Gynecologic Society dinner meeting, St. Louis Medical 
Society Bldg. 

Missouri Surgical Society dinner meeting, University Club. 

Missouri Ophthalmological Society dinner meeting, Lido Room. 


6:30 p.m. Missouri Radiological Society dinner meeting, Coach Room. 


6:30 p.m. Missouri Society of Internal Medicine, Stockholm Room. 


Tuesday, March 10, 1964 


8:00 a.m. Registration. Lobby floor. 

9:00 a.m. Panel: Hits and Misses in Current Drug Therapy, Khorassan Room. 
Moderator: Edward D. Kinsella, M.D., St. Louis. 

Cancer Chemotherapy, C. Gordon Zubrod, M.D., Bethesda, Md. 
The Use of Thyroid, Thyroxine and Triido-thyronine in the Treat- 
ment of Hypothyroidism and Other Conditions, Paul H. 
Lavietes, M.D., New Haven, Conn. 

MAO Inhibitors, Their Use, Misuse and Therapeutic Effects, 
Nathan S. Kline, M.D., Orangeburg, N. Y. 

9:00 a.m. Panel: Adolescent Medicine, Lido Room. 

Moderator, James P. King, M.D. 

Panelists: 

Felix P. Heald Jr., M.D., Washington, D. C. 

Willard M. Allen, M.D., St. Louis. 

Robert J. Corday, M.D., St. Louis. 

10:30 a.m. Intermission to View Exhibits. 


Carl R. Ferris, M.D., Kansas City, presiding. 

11:00 a.m. Subject to be announced, M. D. Overholser, M.D., Columbia. 
Missouri University Medical Award Winner. 

11:30 a.m. Polyglandular Disease, Edwin H. Ellison, M.D., Milwaukee, Wis. 

12:00 noon University of Missouri Medical Alumni Association Luncheon, 
Zodiac Room. 


1:30 p.m. Medical Economics Session, Khorassan Room. 

The Problem of Hospital Costs. 

Moderator: Curtis H. Lohr, M.D., St. Louis. 

Panelists: 

Mr. Harry M. Piper, St. Louis, Administrator of St. Luke’s 
Hospital. 

Mr. John B. Warner Jr., St. Louis, Director of St. Louis L^ni- 
versity Hospitals. 


ADVERTISEMENTS 


127 



The discharged 
mental patient . . . 
and Thorazine ® 

brand of chlor promazine 


“The average 'practitioner is quite capable of handling the vast majority of ex-institu- 
tionalized patients by regulation of medication, reassurance, manipulation of the en- 
vironment where necessary, and . . . other technics Kune, n.s.: Postgrad. Med. 27x20 (May) i960. 


The family physician must often assume respon- 
sibility for the discharged mental patient. Thora- 
zine (chlorpromazine, sk&f) can be a valuable 
adjunct to the continuing care of this patient, 
because it helps prevent relapses by insulating 
him from the impact of stressful experiences. 
For successful rehabilitation and prevention of 
rehospitalization, however, the former mental 
patient— and often his family— also needs the 
guidance and counsel of his physician. 

Many physicians are surprised by the high doses 
of Thorazine (chlorpromazine, SK&F) used in pa- 
tients released to their care from mental hospitals. 
This surprise may be expressed by a drastic re- 
duction in dosage “to play it safe” — with serious 
consequences for the patient. 

The successful maintenance of former mental pa- 
tients requires adequate, often “high” dosage, and 
often for prolonged periods of time. Fortunately, 
these dosages do not mean greater risks for the 


patient. On the contrary, there is much less risk 
of serious side effects once a patient has become 
gradually accustomed to Thorazine (chlorproma- 
zine, sk&f)— regardless of dosage — over a period of 
a few months. Continuing therapy is almost 
always well tolerated, and is essential to most 
patients’ continued well-being. 

Brief Summary: Thorazine (chlorpromazine, sk&f) has been 
successfully used for 10 years in the treatment of mental and 
emotional disturbances, and has proven highly effective in 
the maintenance therapy of former hospitalized mental pa- 
tients. Principal side effects: The most frequently encountered 
side effect is transitory drowsiness. Other occasional side 
effects include: dry mouth, nasal congestion, constipation, 
miosis, dermatological reactions, photosensitivity, jaundice, 
hypotension, increased appetite and weight; very rarely, 
mydriasis, agranulocytosis, extrapyramidal symptoms. 
Contraindications: Comatose states or in the presence of 
excessive amounts of C.N.S. depressants. 

For complete prescribing information, please see PDR or 
available literature. 

Smith Kline & French Laboratories 



128 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
February, 1964 


Frank R. Bradley, M.D., St. Louis, Director Emeritus, Barnes 
Hospital. 

James P. Murphy, M.D., St. Louis. 

Morris Alex, M.D., St. Louis. 

Charles A. Nester, M.D., St. Louis. 

3:00 p.m. Intermission to View Exhibits. 

3:30 p.m. Panel: Treatment of Hiatus Hernia and Esophagitis, Lido Room. 
Moderator: Hector W. Benoit Jr., M.D., Kansas City. 

Panelists: 

Donald B. Effler, M.D., Cleveland, Ohio. 

Nicholas C. Hightower, M.D., Temple, Tex. 

Richard Schatzki, M.D., Boston, Mass. 

3:30 p.m. Panel: Long Term Management of Ischemic Heart Disease, Kho- 
rassan Room. 

Moderator: Guy D. Callaway Jr., M.D., Springfield. 

Coronary Arteriography: Clinical and Psychological Correlations, 
Richard S. Ross, M.D., Baltimore, Md. 

Impending Myocardial Infarction, R. E. Beamish, M.D., Winnipeg, 
Canada. 

Prophylactic Anticoagulent Therapy After Myocardial Infarction, 
Herbert E. Griswold Jr., M.D., Portland, Oregon. 

Sponsored by the Missouri Heart Association. 

5:45 to 7:15 p.m. St. Louis University Medical Alumni Reception, Stock- 
holm Room. 

6:00 to 7:15 p.m. Washington University Medical Alumni Reception, Coach 
Room. 

7:30 p.m. Banquet in Honor of Past Presidents, Khorassan Room. 

Wednesday, March 11, 1964 

7:30 a.m. House of Delegates Breakfast Meeting, Chase Club. 


FRESH UP with SEVEN-UP! 





ADVERTISEMENTS 


129 



Constant diagnostic and cardiac distress 
information around the clock — with immediate 
alarm if irregularities in heart rhythm occur — 
are automatically provided by this new Sanborn 
Viso-Monitor. This compact, integrated bedside 
system — for recovery room, intensive care or 
OR use — includes a built-in electrocardiograph, 
pacemaker, cardiotachometer and eight 
illuminated alarm indicators. 

Your patient's ECG is recorded automatically 
for 10 seconds at either pre-set intervals or at 
the onset of any of four distress conditions. It 
can also be taken during pacing, for valuable 
knowledge of the patient’s response to pacing. 
Heart rate is continuously displayed on the 
front panel meter, which has adjustable upper 
and lower thresholds to activate alarms. 
Bradycardia, tachycardia, peripheral pulse loss, 
arrest and each QRS complex, as well as 
operating conditions of the Viso-Monitor, are 
shown by warning lights. Internal or external 
pacemaking current is provided by the 
instrument, with adjustments for current and 
rate and positive safeguards to prevent 
accidental pacing. Audible alarm is supplied by 
an optional Remote Alarm unit, which also 
duplicates visual indicators and heart rate 
meter of main instrument. The new Model 780 
Viso-Monitor is SI 850, the Remote Alarm unit 
S250, and DC Defibrillator SI 370 
(F.O.B. Waltham, Mass., continental U.S.A.). 


your 

heart patient 
is in 
good 
hands 


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SANBORN COMPANY 


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8621 East 55th St., Fleming 3-2038 


New Members 


Tanous D. Faris, M.D., 8852 Flamingo Court, 
St. Louis, has become a member of St. Louis 
Medical Society. Dr. Faris is a native of Provi- 
dence, R. I., received his preliminary education 
at Providence College, and his M.D. degree at 
Tufts University in 1959. He specializes in sur- 
gery. 

Thomas F. Frawley, M.D., 1325 S. Grand 
Blvd., St. Louis, has become a member of St. 
Louis Medical Society. Dr. Frawley is a native 
of Rochester, N. Y., received his preliminary edu- 
cation at the University of Rochester, and his 
M.D. at the University of Buffalo in 1944. He 
specializes in internal medicine. 

Paul L. Friedman, M.D., 7712 Cornell Ave., 
St. Louis, has become a member of St. Louis 
Medical Society. Dr. Friedman is a native of St. 
Louis, received his preliminary education at 
Washington University, and his M.D. degree at 
Washington University in 1957. He specializes 
in anesthesiology. 

William B. Hardin Jr., M.D., 660 S. Kingshigh- 
way Blvd., St. Louis, has become a member of 
St. Louis Medical Society. Dr. Hardin is a native 
of Houston, Tex., received his preliminary edu- 
cation at Rice University, and his M.D. degree at 
the University of Texas in 1957. He specializes 
in neurology. 

Robert S. Hicks, M.D., 4500 W. Pine Blvd, 
St. Louis, has become a member of St. Louis 
Medical Society. Dr. Hicks is a native of Eldo- 
rado, Ark, received his preliminary education 
at Hendrix College, and his M.D. degree at the 
University of Arkansas in 1958. He specializes 
in psychiatry. 

Lanny L. Johnson, M.D, 2001 Lindbergh 
Blvd, St. Louis, has become a member of St. 
Louis Medical Society. Dr. Johnson is a native 
of Wayne, Mich, received his preliminary edu- 
cation at Michigan State University, and his 
M.D. degree at Wayne State University in 1959. 
He specializes in orthopedics. 

James H. Jones, M.D, 2323 37th St, N.W, 
Washington, D. C, has become a member of St. 
Louis Medical Society. Dr. Jones is a native of 
St. Louis, received his preliminary education at 
St. Louis University, and his M.D. degree at St. 
Louis University in 1959. He specializes in oph- 
thalmology. 

George C. Kaiser, M.D, 1325 S. Grand Blvd, 
St. Louis, has become a member of St. Louis 
Medical Society. Dr. Kaiser is a native of Bronx, 


N. Y, received his preliminary education at Le- 
high University, and his M.D. degree at John 
Hopkins University in 1953. He specializes in 
surgery. 

Lucy J. King, M.D, 4940 Audubon St, St. 
Louis, has become a member of St. Louis Medi- 
cal Society. Dr. King is a native of Vandalia, 
Illinois, received her preliminary education at 
Washington University, and her M.D. degree at 
Washington University in 1958. She specializes 
in psychiatry. 

Robert P. Kloecker, M.D, 9616 Lackland 
Road, St. Louis, has become a member of St. 
Louis Medical Society. Dr. Kloecker is a native 
of St. Louis, received his preliminary education 
at Notre Dame University, and his M.D. degree 
at St. Louis University in 1959. He specializes 
in obstetrics. 

Daniel K. Lane, M.D, 3720 Washington Blvd, 
St. Louis, has become a member of St. Louis 
Medical Society. Dr. Lane is a native of St. 
Louis, received his preliminary education at 
Princeton University, and his M.D. degree at 
Washington University in 1959. He specializes 
in dermatology. 

John D. Lauer, M.D, 3720 Washington Blvd, 
St. Louis, has become a member of St. Louis 
Medical Society. Dr. Lauer is a native of Alton, 
111, received his preliminary education at John 
Carroll University, and his M.D. degree at St. 
Louis University in 1956. He specializes in ra- 
diology. 

Manuel F. Menendez, M.D, 11084 Eckelkamp 
Drive, St. Louis, has become a member of St. 
Louis Medical Society. Dr. Menendez is a na- 
tive of Havana, Cuba, received his preliminary 
education at Marti Academy and his M.D. de- 
gree at Havana Medical School in 1956. He spe- 
cializes in pathology. (Dr. Menendez was incor- 
rectly listed as Amando Menendez in the Janu- 
ary issue.) 

Alva Moore, M.D, 2814 N. Taylor Ave, St. 
Louis, has become a member of St. Louis Medi- 
cal Society. Dr. Moore is a native of Monroe, 
Ark, received his preliminary education at Phil- 
ander Smith College, and his M.D. degree at 
Meharry College in 1937. He specializes in in- 
ternal medicine. 

Ferris N. Pitts, M.D, 4940 Audubon St, St. 
Louis, has become a member of St. Louis Medi- 
cal Society. Dr. Pitts is a native of St. Louis, re- 
ceived his preliminary education at Washington 


Special cough formula for children 

Pediacof 

Each teaspoon (5 ml.) contains codeine phosphate 5 mg. f 

Neo-Synephrine® hydrochloride (brand of phenylephrine hydrochloride) 2.5 mg., 

chlorpheniramine maleate 0.75 mg. and potassium iodide 75 mg. 

soothing decongestant and expectorant 



bright red, 
pleasant-tasting, 
raspberry-flavored syrup 

Pediacof is different. It is designed espe- 
cially for children, and each ingredient is in 
the right proportion. The potassium iodide 
in Pediacof is so well masked that it is virtu- 
ally unnoticeable. Children like the sweet 
raspberry flavor of bright red Pediacof. 

Dosage: Children from 6 months to 1 year, 
14 teaspoon; from 1 to 3 years, Vi to 1 tea- 
spoon; from 3 to 6 years, 1 to 2 teaspoons; 
and from 6 to 12 years, 2 teaspoons. These 
doses are to be given every four to six hours 
as needed. 


How supplied: Bottles of 1 6 fl. oz. 


Available on prescription only. 
Exempt Narcotic. 


Side effects: The only significant untoward 
effects that have occurred are mild anorexia 
and an occasional tendency to constipation. 
However, discontinuance of Pediacof has 
seldom been required. Mild drowsiness oc- 
curs in some patients but, when cough is 
relieved, the quieting effect of Pediacof is 
considered beneficial in many instances. 

Precautions and contraindications: Patients 
with tuberculosis or those who are known 
to be sensitive to iodides should not be given 
Pediacof. 

Caution should be exercised if Pediacof is 
administered to patients with cardiac dis- 
orders, hypertension or hyperthyroidism. 

Warning: May be habit forming. 

Winthrop Laboratories 
New York, N.Y. 


W/nthrop 



132 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
February, 1964 


University, and his M.D. degree at Washington 
University in 1955. He specializes in psychiatry 
and pediatrics. 

Thomas E. Rusan, M.D., 243 E. Kirkham 
Road, St. Louis, has become a member of St. 
Louis Medical Society. Dr. Rusan is a native of 
St. Louis, received his preliminary education at 
the University of Illinois, and his M.D. degree 
at Meharry College in 1945. He specializes in 
general practice and obstetrics and gynecology. 

Donald G. Spalding, M.D., 7715 Weston Place, 
St. Louis, has become a member of St. Louis 
Medical Society. Dr. Spalding is a native of 
Granite City, 111., received his preliminary edu- 
cation at Central College, and his M.D. degree 
at St. Louis University in 1960. He specializes in 
radiology. 

Andrew D. Spencer, M.D., 2601 N. Whittier 
St., St. Louis, has become a member of St. Louis 
Medical Society. Dr. Spencer is a native of East 
Chicago, Ind., received his preliminary educa- 
tion at Indiana University, and his M.D. degree 


at Indiana University in 1954. He specializes in 
surgery. 

Mark A. Stewart, M.D., 4950 Audubon St., St. 
Louis, has become a member of St. Louis Medi- 
cal Society. Dr. Stewart is a native of Yeovil, 
England, received his preliminary education at 
Cambridge University, and his M.D. degree at 
the University of London and St. Thomas Hos- 
pital Medical School in 1956. He specializes in 
psychiatry. 

C. M. Turner, M.D., 3861 St. Louis Ave., St. 
Louis, has become a member of St. Louis Medi- 
cal Society. Dr. Turner is a native of Muskogee, 
Okla., and received his M.D. degree at Meharry 
Medical College in 1947. He specializes in ob- 
stetrics and gynecology. 

Joe R. Utley, M.D., Whiteman Air Force Base, 
has become a member of St. Louis Medical So- 
ciety. Dr. Utley is a native of Carter, Okla., re- 
ceived his preliminary education at Oklahoma 
City University, and his M.D. degree at Wash- 
ington University in 1960. He specializes in sur- 
gery. 



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: in is almost invariably a presenting 
symptom in cases of skeletal muscle 



In some instances, the pain subsides on relaxation of the muscles in spasm. In others, 
relaxant therapy alone fails to give adequate relief, and supplementary 
analgesia (and possibly sedation) are indispensable, as in cases of: 


provocative paill , when muscle spasm is triggered by some painful 
underlying musculoskeletal defect. 

residual pain, when relaxation of severe spasticity leaves a degree 
of myalgia that tends to reinvoke spasm. 


Severe pain, when the degree of pain is such as to cause persistence 
of symptoms in spite of relaxant therapy. 

emotionally aggravated pain, when anxiety or agitation creates tension 
that thwarts the efficacy of both relaxant and analgesic medication. 

In such cases, Robaxisal and Robaxisal-PH have proven highly effective in assuring decisive 
and comprehensive relief. The Robaxisal formula— of Robaxin (methocarbamol), 
the potent muscle relaxant, together with aspirin, the time-tested and proved analgesic- 
produces higher plasma salicylate levels than equivalent doses of aspirin alone, and serves 
effectively to control both spasm and pain. Robaxisal-PH’s combination of 
Robaxin (methocarbamol) with the analgesic-sedative ingredients of the Phenaphen 
formula— including phenobarbital— helps additionally to ease apprehension. 


ROBAXISAL fc 




Each pink-and-white laminated Tablet contains: 

Robaxin (methocarbamol, Robins) 400 mg. Aspirin (5 gr.) 325 mg. 

U.S. Pat. No. 2770649 


ROBAXISAE-PH 

Each green-and-white laminated Tablet contains: 

Robaxin 400 mg. Phenacetin (\Vz gr.)... 97 mg. Hyoscyamine sulfate 0.016 mg. 

(methocarbamol, Robins) Aspirin [IV\ gr.) 81 mg. Phenobarbital (Vs gr.)....8.1 mg. 

(Warning: May be habit forming) 



“PAIN & SPASM” 

- a two-headed dragon! 


Robaxisal and Robaxisal-PH are indicated in 
strains and sprains, painful disorders of the back, 
“whiplash” injury, myositis, pain and spasm asso- 
ciated with arthritis, torticollis, and headache asso- 
ciated with muscular tension. 

Side effects such as lightheadedness, slight drowsi- 
ness, dizziness and nausea may occur rarely in 


patients with intolerance to drugs, but they usually 
disappear on reduction of dosage. 

Contraindicated for patients hypersensitive to any 
component of the formulations. There are no spe- 
cific contraindications to methocarbamol, and un- 
toward reactions are not to be expected. 


A. H. ROBINS CO., INC., Richmond 20, Virginia 


County Society News 


FIRST DISTRICT 

JOSEPH L. FISHER, ST. JOSEPH, COUNCILOR 
Ruchanan County Medical Society 

The election meeting of the Buchanan County 
Medical Society was held in Hotel Robidoux, 
St. Joseph, following a dinner on December 4. 
Officers chosen to serve the Society in the com- 
ing year were: Dr. Herbert C. Senne, President- 
Elect; Dr. William Redmond, Vice President; Dr. 
Irwin Rosenthal, Secretary; Dr. Robert W. Kie- 
ber, Treasurer for the 11th consecutive year. 

Dr. Jacob Kulowski was elected to the board 
of censors, and Dr. Ernest E. Wadlow was re- 
elected delegate to the State Medical Associa- 
tion. Alternate delegates selected were: Drs. 
E. F. Butler and Thompson E. Potter. Other of- 
ficers chosen were: Dr. Caryl A. Potter Jr., mem- 
ber committee on public policy; Dr. George W. 
Forman, trustee to 1969; Dr. John R. McDaniel, 
member of the executive committee. 

The newly elected officers will be installed at 
the annual dinner and installation meeting of the 
Society for doctors and wives on December 12 
at Hotel Robidoux. Dr. William B. Rost, Pres- 
ident-Elect during 1963 will assume the pres- 
idency at the meeting. Dr. John R. McDaniel, 
retiring president, will preside at the meeting 
and serve as installing officer. 

Arrangements for the installation dinner and 
meeting were made by the program committee 
of which Dr. F. Gregg Thompson III, is chair- 
man, serving with Drs. Manson B. Pettit and 
Edmund W. Kline. 

William Redmond, M.D., Secretary 

Grand River Medical Society 

The annual Christmas meeting of the Grand 
River Medical Society and its Woman’s Auxiliary 
was held at the Strand Hotel in Chillicothe on 
Thursday night, December 12. The meeting 
room was suitably decorated for the occasion by 
members of the Auxiliary and the spirit of Christ- 
mas encompassed the entire evening’s festivities. 
A social hour of true Christmas fellowship in- 
itiated the evening’s program with more than 60 
doctors, wives and guests participating. The din- 
ner following the social hour was of top Christ- 
mas variety. The formal program for the evening 
was highlighted by a short talk by Dr. Kenneth 
Hollweg of Kansas City, President of the Mis- 
souri State Medical Association. 


President Hollweg gave a most interesting re- 
sume of a number of meetings which he had at- 
tended this year as President of the State As- 
sociation and explained a few projects of special 
interest to his audience. Ray McIntyre, Field 



Dr. Vandiver, Mrs. Hollweg, Dr. Gary, Mrs. Vandiver, 
President Hollweg and Mrs. Gary were seated at the 
head table. 


Secretary of the State Medical Association, spoke 
briefly concerning the status and needs of the 
Missouri State Medical Foundation. 

Special music for the occasion was furnished 
by the son of Dr. and Mrs. Gearhart of Bethany 
who plays the harp exceedingly well. 

President George Gary of Marceline conduct- 
ed the meeting in top fashion and it was difficult 
to determine whether it was with pleasure or re- 
gret that he turned over the gavel to the incom- 
ing President, Dr. James Sweiger of Maysville at 
the close of the meeting. Members of the society 



Dr. Gary turned over the gavel to the incoming pres' 
ident. Dr. Sweiger. 


134 






some may 
need the 
combined 
formula 



gyp 







«kj| 

1 *i 


■M. 



ACHROCIDIN 

TETRACYCLINE HCI-ANTI HISTAMINE-ANALGESIC COMPOUND 


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ACHROMYCIN® Tetracycline HCI . . 125 mg. Salicylamide 150 mg. 

Acetophenetidin (Phenacetin) .... 120 mg. Chlorothen Citrate 25 mg. 


Effective in controlling tetracycline-sensitive bacterial infection and providing symptomatic relief in 
allergic diseases of the upper respiratory tract. Possible side effects are drowsiness, slight gastric 
distress, overgrowth of nonsusceptible organisms, tooth discoloration. The last named may occur 
only if the drug is given during tooth formation (late pregnancy, the neonatal period, early child- 
hood). Average Adult Dosage: 2 Tablets four times daily. 


LEDERLE LABORATORIES, A Division of AMERICAN CYANAMID COMPANY, Pearl River, New York 







136 


ORGANIZATION ACTIVITIES 


Missoubi Medicine 
Febbuaby, 1964 



The audience included the immediate Past President, 
Dr. Dowell. 


and their wives were honored to have Dr. and 
Mrs. Hollweg as special guests for the occasion 
and hope they will return soon. A number of 
pharmaceutical representatives of the area were 
present as guests to participate in the entire eve- 
ning festivities. 

Jack L. Vinyard, M.D., Secretary 


SIXTH DISTRICT 

O. B. BARGER, HARRISONVILLE, COUNCILOR 

Lafayette-Ray County Medical Society 

The Lafayette-Ray County Medical Society 
held its December meeting at the Sheraton Elms 
Hotel in Excelsior Springs. Christmas spirit rang 
high and was not dampened by cold weather, 
snow and ice. After an enjoyable meal, excellent 
-entertainment was provided and apparently met 
with approval by all present. All arrangements 
and preparations were made by the Lafayette- 
Ray County Medical Society Auxiliary. 

A short business meeting was held at which 
time officers were elected for the coming year. 
Results of the election are as follows: President, 
Wilbur Fulkerson, M.D., Higginsville; President- 
Elect, Wayne Boydston, M.D., Odessa; Secretary- 
Treasurer, William La Hue, M.D., Lexington; 
Delegate, Lafayette County, Joe Ward, M.D.; 
Alternate, William La Hue, M.D.; Delegate, Ray 
County, George DeVault, M.D.; Alternate, Isa- 
•dore Goldberg, M.D. 

Wayne Boydston, M.D., Secretary 

West Central Missouri Medical Society 

The regular monthly meeting of the West Cen- 
tral Missouri Medical Society was held in Butler, 
December 12, at Glenn’s Cafe. The usual social 


hour with visitation of members, wives and 
guests opened at 6:30 p.m. and was followed by 
a nice steak dinner. 

Following the meal President-Elect, Carter W. 
Luter, took charge of the meeting in the absence 
of President Edward Jones who was unable to 
attend due to a death in the family. 

The scientific program for the evening was 
furnished by the Committee on Maternal Wel- 
fare of the Missouri State Association. 

The panel discussion was on the subject, “Ma- 
jor Causes of Maternal Mortality With Special 
Reference to Western Missouri.” The physicians 
making up the panel were from the obstetrical 
service at St. Luke’s Hospital in Kansas City, 
made up of Dr. Leonard A. Wall, Robert A. 
Slickman and Thomas J. Fritzlen. A case was 
presented in which a maternal death occurred— 
the history and physical and management of the 
case were explained in detail. The panel dis- 
cussed the pros and the cons of the case and the 
management, and then asked for open discus- 
sion. These are always interesting presentations 
and we were pleased to have these men bring 
such a fine program. The discussions are never 
held in the spirit of criticism as they explained, 
but to bring out suggestions of a constructive 
nature to help all should we be faced with a 
similar situation. 

The president bypassed the reading of the 
minutes of the previous meeting and went ahead 
with some business at hand. The Society voted 
$100.00 to the MSMA Student Loan Fund. The 
delegates and alternates for the coming 1964 
meeting of the MSMA in St. Louis were elected 
as follows: Cass County, Edward S. Jones, Har- 
risonville, Delegate; A. W. Ecklund, Pleasant 
Hill, Alternate. Bates County, A. L. Hansen, But- 
ler, Delegate; C. W. Luter, Butler, Alternate. 
Vernon County, Rolla Wray, Nevada, Delegate; 
Roy Pearse, Nevada, Alternate. Cedar County, 
Robert Magee, Eldorado Springs, Delegate; Wil- 
liam B. Richter, Stockton, Alternate. St. Clair, 
Don Giesler, Osceola, Delegate; Robert Browns- 
berger, Appleton City, Alternate. 

The president-elect will have his committees 
appointed in early January. It was stressed that 
the delegates make every effort to be present 
from the opening until the close of the session in 
St. Louis, and if not able to attend, to be sure 
and have their alternate designated and proper- 
ly endorsed. 

There being no further business, the meeting 
adjourned until the January meeting in Harrison- 
ville. 


Carter W. Luter, M.D., Secretary 



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Sodium citrate 85 mg. 


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tolerated but in some patients drowsiness, dizzi- 
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Literature on request 

ENDO LABORATORIES Richmond Hill 18, New York 



The Council 


The Council met at Hotel Chase-Park Plaza, St. Louis, 
December 7, 8, 1963, with Byron M. Stuart, M.D., Boon- 
ville, Chairman, presiding. Those present were Drs. 
Stuart; James M. Macnish, St. Louis; Paul R. Whitener, 
St. Louis; O. B. Barger, Harrisonville; H. W. Benoit Jr., 
Kansas City; Doyle C. McCraw, Bolivar; E. A. Strieker, 
St. James; W. D. English, Cardwell; Kenneth C. Holl- 
weg, Kansas City; Leonard T. Furlow, St. Louis; J. I. 
Matthews, Jefferson City; Charles R. Doyle, St. Louis; 
H. M. Hardwicke, Jefferson City; Vernon E. Wilson, 
Columbia; Messrs. Allen D. Smith, Kansas City; Hol- 
lister Smith, St. Louis; Edgar Mothershead, St. Louis; 
Gary Schnedler, Springfield; Frank Woolley, Chicago; 
Lemoine Skinner, Jordan Singleton, Thomas P. Fox, 
Ray McIntyre, T. R. O’Brien, St. Louis; Misses Peggy 
Heileg and Helen Penn, St. Louis. Attending a portion 
of the meeting were Drs. J. V. Finnegan, St. Louis; 
James A. Kinder, Cape Girardeau; William D. Perry, 
St. Louis; Carl D. Siegel, Sedalia; James N. Haddock, 
Webster Groves; Byron E. Watts and Frederick O. 
Tietjen, Jefferson City; Mr. James Foristel, Washington, 
D. C. 

UNITED FUND 

Mr. O’Brien announced that the Association had re- 
ceived a plaque from the United Fund, all persons in 
the office contributing and a larger amount than last year 
being given. 

MR. SMITH 

Dr. Benoit introduced Mr. Allen D. Smith, in charge 
of communications for the Jackson County Medical So- 
ciety. 

BLOOD BANKS 

Dr. Benoit discussed the blood bank situation in Kan- 
sas City and presented H.R. 8426 which had been in- 
troduced into the Congress. The bill reads: “Be it en- 
acted by the Senate and House of Representatives of 
the United States of America in Congress assembled, 
That it shall not be deemed to be an act in restraint 
of trade under any law of the United States for any 
nonprofit blood bank or physician to refuse, or to join 
together with any other person or persons in refusing, 
to obtain from or to accept delivery of human blood or 
human blood plasma from any other blood bank.” 

The following resolution which was introduced at 
the AM A session by Dr. Richard H. Kiene, delegate, and 
appproved by the reference committee and the House 
of Delegates of the AMA was presented: 

Whereas, House Resolution No. 8426 of the 88th Congress of 
the United States would provide that a refusal of non-profit 
blood banks and of physicians to obtain blood and blood plasma 
from other blood banks shall not be deemed to be acts in re- 
straint of trade under the laws of the United States ; and 
Whereas, Non-profit blood banks by procuring blood and 
blood plasma from volunteer donors and scientifically processing 
such materials for human use, provide an essential part of 
medical care in the United States ; and 

Whereas, Physicians who are skilled in clinical pathology 
and hematology voluntarily and without compensation work in 
and direct the technical operation of such non-profit blood 
banks ; and 

Whereas, These physicians are usually members of their 
county, state and national medical associations and their re- 
spective specialty societies ; therefore be it 

Resolved, By the House of Delegates of the American Medi- 
cal Association that it favors enactment of legislation by the 
Congress of the United States, for the intent and purpose for 
which House Resolution 8426 provides and ; be it further 

Resolved, That copies of this resolution be sent by the 


proper offices of the American Medical Association to all mem- 
bers of the House of Representatives and of the Senate of the 
88th Congress of these United States and ; be it further 

Resolved, That a representative of the American Medical 
Association appear before any committee of the House of Rep- 
resentatives or Senate to which this resolution or a similar 
resolution may be referred, and to urge its enactment by the 
Congress of the United States with the recommendation that 
“hospitals” be included with “non-profit blood banks and phy- 
sicians.” 

FIELD SECRETARY’S REPORT 

Mr. McIntyre reported on the following meetings 
which had been held since the last Council meeting: 
September 30, Greene County and 8th Councilor Dis- 
trict, showing “Operation Barnstormer”; the same pro- 
gram at Jackson County Medical Society on Sept. 24; 
the Kansas City Southwest Clinical Society; October 6, 
Maternal Welfare Committee meeting; October 7, Cape 
Girardeau County Medical Society with Dr. Hollweg as 
speaker; October 10 and 11, Physicians and Schools con- 
ference in Chicago which was attended also by Dr. 
Guy N. Magness; October 16, a meeting at Clinton 
with Dr. Hollweg as speaker; October 26, 27, Missouri 
Academy of General Practice in Kansas City, with Dr. 
McCraw being elected president-elect; November 6, 
Public Service Committee; November 11, trip to Perry- 
ville to discuss the hyphenation of Ste. Genevieve Coun- 
ty with the Perry County Medical Society; November 15, 
West Central Medical Society with Dr. Hollweg as 
speaker; November 19, Marion-Ralls-Shelby, at which 
it was brought out that drugs could not be handled by 
druggists for the amount that is paid by the state for 
OASI individuals; November 21, Perry County Medical 
Society, at which was discussed a proposed hyphenation 
of the Perry County Medical Society with Ste. Gene- 
vieve County (now in Mineral Area Society). 

HYPHENATION 

After discussion, in which it was stated that the 
hyphenation of Perry County and Ste. Genevieve was 
approved by the Mineral Area and Perry County So- 
cieties and by doctors in Ste. Genevieve County, on 
motion of Dr. English, duly seconded, it was voted that 
the hyphenation be approved and that a new charter be 
given to the Perry-Ste. Genevieve County Medical So- 
ciety. 

treasurer’s report 

Dr. Doyle presented the report of the Treasurer, 
which on motion of Dr. Doyle, duly seconded, was filed 
for audit. 

BUDGET 

Dr. Doyle presented the following 1964 budget, which 
on motion of Dr. Doyle, duly seconded, was adopted: 


Salaries $ 70,525.00 

Office rent and light 4,700.00 

Postage 5,000.00 

Stationery, printing, supplies 5,000.00 

Journal expense 35,000.00 

Telephone and Telegraph 3,000.00 

Insurance, Emp. pension plan 8,000.00 

Legal and professional fees 3,500.00 

Taxes — payroll 2,200.00 

Travel expense 7,000.00 

Committee expense 51,000.00 

138 


ADVERTISEMENTS 


139 


Post- Graduate Program 

“THE PHYSIOLOGICAL BASIS FOR DIAGNOSIS 
AND TREATMENT OF DISEASE” 

Co-Sponsors 

Department of Internal Medicine 
St. Louis University School of Medicine 
and 

Missouri State Medical Association 

St. Louis University Hospitals 
Firmin Desloge Hospital 
Miller Hall 

Wednesday, March 11, 1964 

Morning Session — Goronwy O. Broun Sr., M.D., Dean, St. Louis University 
School of Medicine— Presiding. 

10:00 New Concepts of Parathyroid Function in Clinical Disease 

Thomas F. Frawley, M.D., Professor of Medicine; Director, Department 
of Internal Medicine 

10:30 The Basis of Therapy of Diabetes Mellitus 

Henry E. Oppenheimer, M.D., Associate Professor of Clinical Medicine 
11:00 Recent Trends in the Study of Iron Metabolism 

Neil I. Gallagher, M.D., Assistant Professor of Medicine 
11:30 Newer Concepts of the Disorders of Iron Metabolism 

Goronwy O. Broun Jr., M.D., Assistant Professor of Medicine 
12:00 General Discussion 

12:30 Lunch— Firmin Desloge Hospital Cafeteria 

Afternoon Session — Ralph A. Kinsella Sr., M.D., Professor Emeritus, 
Department of Internal Medicine— Presiding. 

1:30 Pathophysiology and Therapy in Chronic Pulmonary Insufficiency 
Herbert C. Sweet, M.D., Professor of Clinical Medicine 
2:00 Evaluation of the Hypertensive Patient 

James G. Janney Jr., M.D., Associate Professor of Clinical Medicine 
2:30 Antibiotics and Host Response in the Management of Infectious Disease 
R. William Burmeister, M.D., Instructor in Internal Medicine 
3:00 The Malabsorption Syndrome 

Guy E. Van Goidsenhoven, M.D., Assistant Professor of Medicine 
3:30 General Discussion 

Registration Fee — $10.00, includes lunch 

Send Inquiries to: W. A. Knight Jr., M.D. 

Department of Internal Medicine 
St. Louis University School of Medicine 
1325 South Grand Blvd. 

St. Louis 4, Missouri 


140 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
February, 1964 


Furniture and Fixtures 500.00 

General expense 3,000.00 

MSMF assessment 25,526.00 

MSMF expense 600.00 

Total $224,851.00 


PUBLIC SERVICE 

Dr. Barger gave the report of the Committee on 
Public Service as follows: 

The Committee on Public Service met on November 
6, at the Chase Hotel, St. Louis, with Dr. O. B. Barger, 
Harrisonville, presiding. Others present were: Drs. Ken- 
neth C. Hollweg, Kansas City; Leonard T. Furlow, St. 
Louis; Armand Brodeur, St. Louis; H. M. Hardwicke, 
Jefferson City; Messrs. Tom O’Brien, Ray McIntyre, 
Tom Fox, Lemoine Skinner Jr., Jordan C. Singleton and 
Miss Peggy Heilig, St. Louis. 

King-Anderson Hearings — The Ways and Means Com- 
mittee of the House of Representatives will hold hear- 
ings on the King-Anderson Bill November 18-27. 

MSMA Statement of Opposition — A statement of op- 
position from MSMA has been prepared and this was 
reviewed and approved by the Committee. The state- 
ment includes excerpts from the Cason interim com- 
mittee report on health needs of the aged in Missouri, a 
review of the health care legislation passed by the 
1963 session of the Missouri General Assembly and 
concludes with statistics gathered by the Missouri Di- 
vision of Health concerning the method of payment by 
patients discharged from outstate Missouri hospitals in 
the last six months of 1962. These statistics show that 
of a total of 90,192 cases, only 929 could not pay any 
of their hospitals costs, and of these 929, just 186 were 
aged 65 or over. The committee suggested that when the 
statement is forwarded to the Ways and Means Com- 
mittee, copies be sent to all members of Congress from 
Missouri, the presidents and secretaries of county societies 
and the legislative bulletin mailing list. A state-wide 
news story should also be released at this time, and 
the statement should be printed, in full, in Missouri 
Medicine. 

Notices Regarding Hearings — Mr. O’Brien reported 
that a letter was sent on November 6 to all executive 
secretaries and presidents of county societies and “Op- 
eration Hometown” county chairmen announcing the 
dates of the King-Anderson hearings, and asking that 
local physicians write and personally contact their Con- 
gressmen concerning the King-Anderson bill. 

The Public Service Committee recommends that all 
county societies and auxiliaries be enlisted in the letter- 
writing effort to the members of the Ways and Means 
Committee, as well as to their own representatives, at 
the time of the hearings. 

Public Health — Dr. Hardwicke, Acting Director of 
the Missouri Division of Health, met with the Commit- 
tee for the first part of the meeting. He suggested that 
Public Health has a newly evolving role to play in to- 
day’s doctor-patient relationship and set forth several 
ways in which the Division of Health could be helpful 
in increasing the physician’s effectiveness. These were: 
( 1 ) training public health nurses for assignment as home 
nursing aids in support of the practicing physicians; 
and (2) making available the services of psychiatrists 
to interested doctors for consultation and instructive 
purposes in cases of patients with emotional and psycho- 
neurotic problems. Dr. Hardwicke’s suggestions will be 
referred to the Council for consideration. 


Mobilization for 1964 — The Committee recognized and 
discussed the crucial importance of the outcome of the 
1964 elections to the future of the medical profession, 
and recommends increased activitiy by county societies 
and individual members in this area. 

“ Operation Hometown ” — Only six of 51 societies have 
reported “Operation Hometown” chairmen. The com- 
mittee expressed disappointment in this showing and 
recommends that societies which have not yet gotten 
this project under way be urged to do so immediately, 
by mail and by visits of the Field Secretary'. 

MMPAC — 1963 membership in the Missouri Medical 
Political Action Committee is 280, compared to 375 in 
1962. The Committee feels that personal solicitation for 
memberships will be required in 1964 for greatest ef- 
fectiveness of this important organization. 

“Barnstormer ” — The “Barnstormer” film on political 
action has been shown in Kansas City and Springfield 
under MMPAC auspices and showings have been re- 
quested for Joplin and the Grand River Society. It was ■ 
reported that arrangements are also being made for a 
joint showing for the St. Louis and St. Louis County 
Societies. 

Quackery — After discussion, the Committee passed a 
resolution urging that the State Board of Medical Exam- 
iners secure personnel needed to thoroughly investigate 
all forms of quackery in Missouri, and pledging the full I 
cooperation of the Committee in publicizing the facts • 
uncovered by such investigations. 

Medicine and Religion — An Association Committee on i 
Medicine and Religion has been formed, and the Pub- 
lic Service Committee offers its assistance with publicity, 
as needed, for the meetings and activities of this new 
committee. 

Communications — The Public Service Committee of- 
fers its assistance to local societies and particularly Dr. 
Donald E. Frein of Leeton, Missouri, and the Johnson 
County Medical Society in providing health column ma- 
terials from the AMA and other sources for use if the 
Society wishes to contribute such a column to weekly 
newspapers. The Committee recommends that the gen- 
eral topic of such newspaper columns be discussed at 
the coming meeting of society presidents and secretaries. 

On motion of Dr. Barger, duly seconded, the report 
was accepted. 

STATEMENT ON H.R. 3920 

Copies of the statement of the Missouri State Medical 
Association on H.R. 3920, presented by Dr. Durward 
G. Hall, Representative in Congress, were presented. 
It was stated that the Statement would appear in the 
January issue of Missouri Medicine. 

A statement from the St. Louis County Medical So- 
ciety to the Committee on Ways and Means was given 
to the Councilors. 

INSURANCE 

Mr. O’Brien reported that following the discussion on 
overhead expense insurance for members that he had 
received one bid and that another was in process and 
would be reported at the next meeting. 

It was pointed out that both Jackson County and St. 
Louis Medical Societies have group term life insurance 
available for members and that the carrier wishes to of- 
fer the same coverage to the balance of MSMA mem- 
bership. After discussion, on motion of Dr. Hollweg, 
duly seconded, it was voted that a committee be ap- 



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© J&J, '64 



142 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
February, 1964 


pointed to study this type of insurance program for 
members. 

Dr. Stuart appointed the following committee: Drs. 
Doyle, Furlow, Whitener and Macnish. 

woman’s auxiliary 

Dr. Hollweg said that he had discussed the Advisory 
Committee to the Woman’s Auxiliary with Mrs. Crispell, 
president of the Auxiliary. It has been suggested that in 
the future the Advisory Committee be composed of the 
immediate Past President of MSMA, Chairman of the 
Council and the Councilor from the district in which 
the president of the Auxiliary resides. 

On motion of Dr. Hollweg, duly seconded, this was 
approved. 

The Auxiliary also requested that the Roster issue be 
mailed by MSMA to all members of the Auxiliary. On 
motion of Dr. Barger, duly seconded, it was voted that 
the Association mail rosters to members of the Auxiliary. 

Dr. Hollweg stated that a decision would be made at 
the coming meeting of the Auxiliary whether or not 
their Student Loan Fund would be turned over to 
MSMF. 

MSMF 

Dr. Furlow gave the following report of the finances 
of the Missouri State Medical Foundation: 

Status as of December 6, 1963 

Total Loans to date (224 loans to 

105 students) $104,020.00 

Loans for first semester (40 loans) 

1963-1964 19,000.00 

Balance on hand $ 11,266.30 

In discussion it was brought out that the MSMA 
might advance some money against the assessment for 
1964 in case funds were needed for the second semester; 
also it was pointed out that it would be a good thing to 
get out another letter of solicitation at this time, which 
was agreed to. 

On motion of Dr. Furlow, duly seconded, it was 
voted that the report be accepted and that funds be 
advanced by MSMA if necessary. 

MEETINGS 

Dr. Hollweg reported attending the meeting of the 
Missouri Hospital Association and said that there seemed 
to be good rapport; he reported on the conference on 
“Quackery” sponsored by AMA and the Federal Pure 
Food and Drug Administration, held in Washington, 
D. C.; Mr. McIntyre attended in his place an explora- 
tory committee meeting on “Total Patient Care,” at- 
tended by hospital administrators, nurses, physicians 
and ministers and hospital chaplains. A workshop on this 
subject is planned by the group, and Dr. Whitener, 
Chairman of MSMA Committee on Medicine and Re- 
ligion will serve on the planning committee. 

CIVIL DEFENSE 

Dr. Siegel presented material to the Councilors on 
Health Mobilization Activities, general information con- 
cerning Missouri’s Civil Defense Emergency hospitals 
and the Division of Health’s expanded function training. 
He said that four exercises with training had been held, 
at Carrollton, Cape Girardeau, Havti and Springfield. 


He said that the 200 bed emergency hospitals in the 
state are being up-dated. He reported that in the “Self 
Help” program Missouri ranked fourth in the nation in 
the number of people who had had the course. Dr. 
Siegel requested that the expenses for a postgraduate 
course to be held in Columbia in January be defrayed 
to the extent of $100. 

On motion of Dr. Furlow, duly seconded, it was voted 
to grant the request for $100. 

On motion of Dr. Benoit, duly seconded, the report 
was accepted. 

“under THE CAPITOL DOME” 

Mr. Foristel discussed the Washington AMA office. He 
said that 600 bills of interest to medicine had been in- 
troduced in the present Congress and that it would 
probably go to 900. He said that bills passed that the 
AMA had approved were the medical school construc- 
tion bill, the mental health bill and the mental retarda- 
tion bill. He said that the Medicare program, for de- 
pendents of service personnel, would probably be re- 
duced. He outlined the hearings on the King-Anderson 
bill which began on November 18, the hearings to be 
reopened about the second week in January. He praised 
the work of Representatives Tom Curtis and Durward 
G. Hall in the hearings and also Dr. Annis. 

PROGRAM 

Dr. Matthews presented a preliminary program to 
the Council. Two programs on economics were sug- 
gested and the Council favored “Rising Hospital Costs 
and the Doctor.” 

Mr. Singleton presented a timetable on publicity for 
the Annual Session. 

In discussion of the Annual Session, Mr. Hollister 
Smith suggested that the members of MSMA be enter- 
tained for cocktails and buffet dinner at the St. Louis 
Medical Society Building on Sunday evening. He said 
that if the Council approved, he would present this to 
the Council of St. Louis Medical Society this week. 

On motion of Dr. Hollweg, duly seconded, it was 
voted to accept this invitation if it is forthcoming. 

WILSON-MITCHEM SUIT 

The case of Wilson-Mitchem vs. State Board of Regis- 
tration was discussed. It was said that a motion to in- 
tervene had been filed for the MSMA, and that also 
such action was being filed by the Missouri Osteopathic 
Association. The situation in the State of Washington 
which is considering a short-term school for the purpose 
of conferring M.D. degrees was discussed. 

MEDICAL CENTER 

Dr. Wilson reported that work is being done on the 
Medical School curriculum and that as of June 1, 1964. 
preceptorships will be required and that information on 
community health programs will also be part of the 
curriculum. He said that construction on the new VA 
hospital would begin in 1965, which means there will 
be 1,090 beds when this is completed. He said that if 
more classrooms and laboratories were available, the 
number of students in the medical school could be in- 
creased. 

INFANT AND CHILD CARE 

Dr. Kinder presented the following report for the 
Committee on Infant and Child Care. 


Volume 61 
Number 2 

this conference was that health should be taught in the 
schools as a solid subject the same as mathematics, 
English, etc. 

Smoking in Schools — After discussion, the Committee 
voted to recommend that the Association take a posi- 
tion against smoking in schools and recommend that all 
measures possible be used to prevent smoking by stu- 
dents in schools. 

Dental Health for Handicapped Children — The dental 
health program for handicapped children under the 
State Crippled Children’s Service was discussed. At 
present there are two mobile units purchased by Elks 
Clubs of Missouri, operated by the State Division of 
Health in cooperation with local dentists being used. 
The ultimate goal is five such units. 

In discussion it was brought out that there were no 
state facilities for care of the mentally retarded child 
under 5 years of age needing institutional care. Dr. 
Hardwicke said that money was to be made available 
for planning of institutions and evaluation centers 
which might alleviate this situation. He asked that an 
individual or committee be appointed to work with a 
state committee on this. 

On motion of Dr. Furlow, duly seconded, the Chair- 
man of the Committee on Infant and Child Care was 
designated for membership on this committee. 

On motion of Dr. Hollweg, duly seconded, the report 
was accepted. 

RESOLUTION RE: JEFFERSON CITY BRANCH OF MSMA 

Dr. Tietjen opened the discussion of the resolution 
concerning full-time representation of MSMA in Jefferson 
City by stating that it would be logical to have the 
MSMA office in Jefferson City, the Capital city. He 
stated the reasons for an office in Jefferson City as cen- 
tral location and easily accessible, it is the center of 
activity of all politics, other agencies are located there, 
that year round contact with other groups was impor- 
tant. 

Dr. Watts said that someone was needed in Jefferson 
City at all times for contact with the Division of Health 
and other departmental heads; that too much depends on 
one person, Tom O’Brien, but that constant contact was 
needed; that 53 state organizations have headquarters 
in Jefferson City, the MSMA and LPN being the only 
health organizations not having offices there. 

Questions raised dealt with the cost of such an of- 
fice, the success of MSMA in the last General Assembly, 
amount of personnel needed in such an office, members’ 
attitude toward a raise in dues if necessary. The resolu- 
tion and the action of the House was read as follows: 

Whereas, The contacts between government and organized 
medicine are becoming increasingly frequent and intimate, and 
. Whereas, A progressively important function of the execu- 
tive staff (of MSMA) is representation of organized medicine 
to and before various governmental bodies and agencies, and 

Whereas, Such representation would be enhanced by the res- 
idence of a member of the MSMA executive staff at the seat 
of government in Jefferson City; now, therefore be it 

Resolved, That the Council shall make necessary budgetary 
preparations as required for the 1964 opening of a permanent 
branch office in Jefferson City, and be it further 

Resolved, That the Council with the advice of the Executive 
Secretary, designate and/or employ a full-time member of the 
executive staff who shall be resident in Jefferson City as an 
assistant to the Executive Secretary. 

Report of the Reference Committee on Miscellaneous 
Affairs. 

“After hearing many speakers pro and con, the Com- 
mittee recommends that this resolution be returned to 




146 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
February, 1964 


the Council for further study with a request that a report 
be made to the House of Delegates at its annual meet- 
ing in 1964.” 

Dr. Barger moved that the Council take under advise- 
ment and report at the next meeting. This was duly 
seconded. 

Dr. Furlow offered an amendment that a committee 
of the Council be appointed to study the problem. This 
was duly seconded. On vote, the amendment to the 
motion was adopted as was the motion. 

Dr. Stuart appointed a committee as follows: Drs. 
Hollweg, Chairman; Furlow, Doyle, Matthews, Barger 
and Stuart, ex-officio. 

COMMITTEE ON MENTAL HEALTH 

Dr. Haddock presented the report of the Committee 
on Mental Health as follows: 

The Committee on Mental Health met at the Mis- 
souri Hotel, Jefferson City on October 13, with Dr. 
George W. Forman, St. Joseph, chairman, presiding. 
Others present were: Drs. William F. Clary, Springfield; 
G. H. Lawrence, St. Louis; James N. Haddock, Clayton; 
Henry V. Guhleman, Jefferson City; George Ulett, Jeffer- 
son City and Mr. Thomas P. Fox, St. Louis. 

Legislation 72nd General Assembly — Dr. Forman re- 
viewed the legislation relating to mental health, en- 
acted in the 72nd Missouri General Assembly. Discus- 
sion included: (a) Senate Bill No. 56, establishment of 
three Intensive Treatment Centers; (b) Senate Bill No. 
57, establishment of funds for the mental health centers 
in Senate Bill No. 56; (c) Senate Bill No. 109, temporary 
licensure for physicians not citizens of the United States, 
and (d) Senate Bill No. 143 relating to commitment, ac- 
quittal, release and discharge of the mentally ill in crim- 
inal cases. The Missouri Bar Association is preparing an 
analysis of Senate Bill No. 143 to assist the medical 
profession in the implementation of this law. 

Not Enacted — H.B. 675 concerning malpractice ac- 
tions against physicians employed by the state of Mis- 
souri. This bill was judged by the committee as good 
legislation and worthy of introduction in the 73rd Gen- 
eral Assembly. 

The Committee approved request of Dr. Ulett that 
appreciation be recorded from the Division of Mental 
Diseases to MSMA for support and assistance with the 
program introduced by Dr. Ulett, S.B. 56. 

Division of Mental Diseases — Dr. Ulett stated that 
future plans include reduction in the number of patients 
hospitalized who should not be in mental hospitals and 
the utilization of such funds to better advantage. Care 
of patients who require hospitalization as well as new 
facilities to render such care will be given top priority. 

Plans are under consideration for centers to care for 
retarded children, across the state. Such services will 
include for example: out-patient day care rendered to 
children brought to the center and treated during the 
day while parents are employed. Purchase of land in 
Springfield, to provide one such center is now under 
consideration. 

As recommended in President Kennedy’s program, 
Missouri Mental Health Centers will include in-patient, 
out-patient, and care for retarded children. Plans, how- 
ever, will be made with full awareness of the shortage 
of medical staff in Missouri. 

Dr. Ulett called attention to the fact that the Presi- 
dent’s program could attract psychiatric staff away from 


state programs creating a more acute shortage than that 
which exists at present. 

The Committee agreed that for the present, Missouri 
should concentrate on the implementation of Dr. Ulett’s 
program, the establishment of the three intensive care 
centers including (a) in-patient, (b) out-patient, and 
(c) day care for mentally retarded. The Committee 
suggested that such action would, for the present, satis- 
fy the comprehensive treatment program recommended 
by the President. 

Psychologists in California — Dr. Ulett reported on 
attempts of psychologists in the state of California to 
expand their field and status to the level of psychiatrists. 

It was suggested that the Association office address 
the Southern California District Asssociation for more 
information. Dr. Haddock will furnish the address. 

Study of State Hospital No. 2 at St. Joseph — Dr. 
Ulett reported on the latest developments of investiga- 
tion by an Interim Legislative Committee of the State 
Mental Hospital at St. Joseph. Dr. Ulett reported his 
complete support of the superintendent in his adminis- 
trative actions investigated by the Interim Committee. 

Question was raised regarding monopoly of news 
media in the City of St. Joseph. It was suggested that 
inquiry of such monopoly should be pursued by 
MSMA. Dr. Clary will provide information regarding a 
similar experience in another state. 

It was suggested that in the interest of providing the 
best patient care in Missouri Mental Institutions, and to 
protect representatives of the medical profession while 
in the process of providing such care, developments in 
St. Joseph be followed closely by the committee and 
the MSMA. 

If some action seems necessary, it was unanimously 
agreed that the St. Joseph Mental Health Association 
might consider appointment of a special committee of 
physician members of the Eastern and Western Mis- 
souri branches of the American Psychiatric Association 
to study conditions at St. Joseph State Hospital No. 2. 

Mental Health Insurance — Dr. Lawrence reported 
that he is awaiting information from Dr. Al Frank of 
the Missouri Eastern Division — Committee on Insurance. 
It was agreed that further study should be made in- 
cluding reports of negotiation with labor unions on new 
and revised labor contracts which include mental health 
coverage. 

Future Plans — Dr. Forman reviewed letter of October 
10, addressed to all county secretaries regarding local 
mental health committees, speakers, and topics for dis- 
cussion. It was reported that to date, St. Louis County 
was the only medical society which has reported a local 
committee on Mental Health. It was agreed that three 
months time should be allowed for action on the recom- 
mendations. Results will be reported to Dr. George 
Forman and if necessary, a follow-up letter will be 
written urging action by the county societies. It was 
agreed that the second letter could include an endorse- 
ment of the Missouri Division of Health and the Mis- 
souri Division of Mental Diseases. 

It was agreed that all interested county societies be 
informed that the Eastern and Western Psychiatric As- 
sociations, as well as the University of Missouri, have 
Speakers Bureaus. 

Missouri Mental Health Association — Attention was 
called to the fact that lay membership of the Missouri 
Mental Health Association should include physicians’ 


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148 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
February, 1964 


wives. Concern was reported to the effect that public 
information is not disseminated correctly by the lay 
members of this organization. 

On motion of Dr. Barger, duly seconded, the report 
was accepted. 

A mental health clinic in Southeast Missouri was dis- 
cussed and Dr. Haddock said that the Committee on 
Mental Health will study this. 

RULES ON S.B. 109 

Dr. Perry presented the following rules and regula- 
tions pertaining to S.B. 109, as approved by the State 
Board of Registration for the Healing Arts: 

Rule No. 1 — (a) The applicant is required to make 
application upon a form prepared by the Board, (b) No 
application will be considered unless fully and completely 
made out on the specified form and properly attested, 
(c) An applicant shall present with the application one 
photograph in size not larger than 3/2 by 5 inches, prop- 
erly attached to the application blank, (d) Completed 
applications shall be sent to the Executive Secretary of 
the State Board of Registration for the Healing Arts, 
Box 4, Jefferson City, Missouri 65102, by the Superin- 
tendent of the hospital, (e) The Board shall charge 
each person applying to it for a certificate of temporary 
licensure to practice as a physician and surgeon in the 
State of Missouri, a fee of five dollars ( $5.00 ) . A fee of 
five dollars ( $5.00 ) shall be charged annually in the 
event the temporary license is renewed. The fee shall 


be sent in the form of a bank draft or postal money 
order or express money order. (Personal Checks Will 
Not Be Accepted. ) 

Rule No. 2 — (a) Applicant shall secure a recom- 
mendation of his moral, ethical and professional con- 
duct from the Superintendent and/or Chief of Staff in 
the hospital in which he desires to work, (b) Appli- 
cants shall notify the Board when they leave the hospital 
where they are employed, (c) Superintendent or Di- 
rector of the hospital to which an applicant wants to 
go, shall notify the Board when an applicant desires to 
leave or move from one hospital to another, (d) Appli- 
cant will be required to appear before the Board at the 
Board’s discretion. 

Rule No. 3 — (a) Executive Secretary will sign the 
temporary license, (b) Executive Secretary will submit 
a list of the names for renewals to the Board for ap- 
proval. 

Rule No. 4 — (a) A letter of certification shall be sent 
only to the Superintendent of the hospital. 

Rule No. 5 — (a) The Board may terminate a tem- 
porary license at its own discretion. 

Rule No. 6 — (a) Superintendent or other officials of 
hospitals approved by the Board for temporary licensure, 
are to furnish the Executive Secretary a list of personnel 
employed in the hospitals as of January 15 and July 15, 
of each year. 

Rule No. 7 — Foreign Graduates — (a) Temporary li- 
censes may be held for a maximum of five ( 5 ) years, 



Y/M 



Volume 61 
Number 2 


ORGANIZATION ACTIVITIES 


149 


renewable annually or until eligible to take the Mis- 
souri State Board examination, (b) Applicant must 
have and show proof of a permanent ECFMG certificate 
or show evidence to the Board that he has passed the 
equivalent licensing Board examination in another state, 
(c) Applicant must file photostatic copies and official 
translations of their medical credentials with the ap- 
plication. Before temporary 7 license can be renewed, 
applicant must have an application completed by their 
school of graduation. 

Rule No. 8 — Interns, Residents and Fellows— (a) In- 
terns, residents and fellows may hold a temporary license 
for a maximum of five (5) years, renewable annually, 
(b) Applicants who are graduates of approved schools 
in the United States and are serving as an intern, resi- 
dent or fellow in hospitals approved by the Board for 
temporary licensure in the State of Missouri, must fur- 
nish satisfactory evidence of having attended an ap- 
proved school and receiving their degree by filing a 
photostatic copy of the professional diploma with the 
application. 

COMMITTEE ON MATERNAL WELFARE 

The report of the Committee on Maternal Welfare was 
presented as follows: 

A meeting of the Committee on Maternal Welfare 
was held at the Missouri Hotel, Jefferson City, on Octo- 
ber 6, with Dr. A. C. Trueblood, Clayton, chairman, 
presiding. Others present were: Drs. C. G. Stauffacher, 


Sedalia; MacDonald Bonebrake, Springfield; E. E. 
Wadlow, St. Joseph; Eugene G. Hamilton, St. Louis; 
Leonard A. Wall, Kansas City; H. M. Hardwicke and 
D. M. Love, Jefferson City; Mr. Clyde Burch and W. W. 
Marshall, Jefferson City; Ray McIntyre and Helen Penn, 
St. Louis. 

Purpose — Dr. Trueblood said that the Committee 
needed to consider two things: to obtain from Mr. Burch 
an opinion as to any legal liability of the committee 
connected with the studies that the committee does 
and the possibility of publishing case reports, and pro- 
gram for the Annual Session. 

Work of Committee - — The studies carried on by the 
Committee were explained to Mr. Burch who is from 
the Attorney General’s office and he answered ques- 
tions from the members present. Discussion included, 
the reporting by the Division of Healdi to the commit- 
tee of maternal deaths would be covered legally be- 
cause it is for research purposes, there is no coercion if 
the involved physician does not wish to discuss the 
case, that identification, even geographical, is not neces- 
sary for the dissemination of information by the com- 
mittee, what could and could not be subpoenaed in any 
legal procedure, the similarity of a published CPC or 
case report to the work of the committee, the possibility 
of changing dates to help in lack of identification, that 
the committee could not legally swear that date is given 
to them correctly. 


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150 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
February, 1964 


Following discussion, Mr. Burch suggested that he 
address a letter to Dr. Hardwicke and outline his ex- 
pressed views on the legal points which could be of 
help to the committee. 

On motion of Dr. Bonebrake, it was voted to ask 
that an informal opinion be given in writing, including 
opinion as to what constitutes identification. 

Annual Session — The value of an annual report by 
the committee at the luncheon meeting was stressed 
and it was stated that the report would come from 
the Eastern Division of the state at the 1964 session. 

Guest Speaker — Dr. Trueblood said that a place had 
been made on the program for a gynecologic presenta- 
tion in a surgical panel on Monday afternoon, March 9. 

After discussion, it was left to Dr. Trueblood to obtain 
the speaker for the afternoon session and to possibly 
ask him to give a talk at the luncheon meeting. It was 
pointed out that the speaker would also be asked to 
speak at a dinner that evening of the St. Louis Gyn. 
Society. 

Dr. Hardwicke said that the letter referred to in the 
report had been received and turned over to the Com- 
mittee. 

On motion, duly seconded, the report was accepted. 

NEXT MEETING 

It was decided that the next meeting would be held 
on February 2, a one day meeting if possible. 

Byron M. Stuart, M.D., Chairman 


SEMINAR FOR FAMILY PHYSICIANS 

The Greater Kansas City Academy of General 
Practice, the Western Missouri District Branch 
of the American Psychiatric Association and the 
G. Wilse and Olive B. Robinson Memorial Fund 
will present the 13th quarterly postgraduate 
seminar for family physicians on February 16. 

Gene L. Usdin, M.D., assistant professor of 
clinical psychiatry at Tulane University, will 
speak on “Neurosis and Trauma.” 

The seminar will be presented at the Neuro- 
logical Hospital, 2625 West Paseo, Kansas City, 
from 2:00 p.m. to 7:00 p.m. 

A panel of physicians of the Greater Kansas 
City area will participate in the latter part of the 
program, discussing further the topic and con- 
ducting a question and answer period. 

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ACCIDENT AND HEALTH INSURANCE 

The Missouri State Medical Association since 1943 has made available to its members a Special Dis- 
ability Income Benefits Policy issued by our “Loyalty Group” Companies now a part of the America 
Fore-Loyalty Group Insurance Companies — the largest casualty-fire underwriting group in the world. 
The low cost at which the policy is offered is made possible through the purchasing power of the 
membership of your association as a whole. 

Now, new plans offering long term income benefits as well as a special Major Hospital-Nurse Expense 
Plan have been added to the program. We suggest you who are already enrolled make sure your policy 
includes the maximum benefits. Those of you not enrolled, we suggest you do so today. Call or Write: 

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From the 
Medical Schools 



WASHINGTON UNIVERSITY 
Shriners’ Hospital Acquired 

Washington University School of Medicine has 
purchased the old Shriners’ Hospital for Crippled 
Children. The property is south of the Medical 
School. The Shriners’ Hospital recently moved 
into a new building in St. Louis County. The 
Medical School will utilize the property, which 
includes the central hospital building, a nurses’ 
hall and a private residence, in their expansion 
and development program. Among possibilities 
are expansion of research facilities in the fields of 
cancer and heart research and installation of 
computer facilities. 

Grants 

Washington University School of Medicine has 
received $4,444,231 in research and training 
grants from the U. S. Public Health Service with- 
in the last six months. 

Of the total, $559,059 will be used for new re- 
search and training projects at the school, Dean 
Edward W. Dempsey, said. The balance of $3,- 
885,172 represents funds for continuation of re- 
search and training programs now underway. 

Largest of the new research grants went to 
Dr. Richard M. Krause, professor of epidemiol- 
ogy. He will use a grant of $78,815 for a chem- 
ical study of hemolytic streptococci. He will in- 
vestigate the hypothesis that complications of 
strep infections such as rheumatic fever or acute 
nephritis may be an allergic reaction to the strep- 
tococci. Many allergic reactions have a known 
chemical base. 

Among special awards was a Research Career 
Award to Dr. Albert Roos, research professor of 
anesthesiology and associate professor of physiol- 
ogy. The award is the highest made by the U. S. 
Public Health Service and supplies full salary for 
five years. 

Dr. Adolph I. Cohen, research assistant pro- 
fessor of ophthalmology and anatomy, received 
a grant of $61,563, which he will use for an 
electron microscopic study of the retina. He will 
do special studies on the nervous pathways with- 
in the retina. 

Computers will be utilized in a study by Dr. 
John A. Stern, professor of medical psychology, 

152 


to evaluate and compare electrical activity re- 
corded from different body sites in psychiatric 
patients. The grant of $56,596 will support the 
project which makes use of psychological mea- 
sures to attempt to classify groups of psychiatric 
patients. The initial work deals mainly with brain 
wave activity and the measures of the autonomic 
nervous system. 

Dr. James O’Leary, professor and head of the 
department of neurology, received two grants 
totaling $46,955. One project will be a survey of 
cerebrovascular disease. He is also engaged in a 
computer project analyzing responses from the 
nervous system. 

Dr. Erik Carlsson, assistant professor of radiol- 
ogy, has received a $46,718 grant. The purpose 
of his investigation is to develop a method of 
applying a thin coating of contrast material to 
the intra-cardiac structure, such as cardiac 
valves, in order to make it possible to visualize 
the dynamics of the heart by x-ray examination. 

Dr. Joseph R. Williamson, assistant professor 
of pathology, will use a grant of $36,495 to study 
the movement of fats in the body between cells. 

A method for earlier diagnosis of glaucoma, an 
eye disease involving internal pressures, is the 
goal of a project of Dr. Robert Moses, associate 
professor of ophthalmology, with support of a 
$29,407 grant. The grant will be used to refine 
technics of measurement of the resistance of 
aqueous humor, a fluid within the eye, and mea- 
surement of the venous blood pressure within the 
eye. 

Dr. William F. Bridgers, instructor in pre- 
ventive medicine and medicine, received a $23,- 
339 grant for a study of genetically controlled 
metabolic regulatory devices in mammals. He 
will study the factors controlling the synthesis 
of amino acids, which are necessary to make 
proteins in the body. 

Dr. Joe W. Grishman, assistant professor of 
pathology, will study factors controlling DNA 
synthesis in the liver with support of a $21,045 
grant. 

A grant of $16,230 to Dr. Vincent Marchesi, 
assistant in pathology, will be used to support 
a study of the structural and enzymatic changes 
associated with small blood vessels and blood 
elements in conditions of acute inflammation. 


Volume 61 
Number 2 


MISCELLANY 


153 


A grant of $10,132 will be used by Dr. Justin 
J. Cordonnier, professor of urology, and Dr. Wil- 
liam T. Bowles, instructor in urology, for the in- 
vestigation of the effects of urinary diversion on 
kidney function. They will study a large group 
of patients who have had surgical removal of 
their bladders for cancer and other disorders and 
evaluate the ileal bladder, a substitute bladder 
constructed from the small intestine. 

Dr. Lucy J. King, instructor in psychiatry, has 
received a grant of $6,000 to study the biochem- 
ical effects of treatments important in psychiatry. 
These include the amphetamine drugs, which are 
mood elevators and which are also used in the 
treatment of children who have brain damage. 
She will also study electrical stimulation, a 
treatment for severe depression. 

Dr. James C. Peden Jr. has received a $9,916 
grant for study of a protein in plasma which is 
necessary for clotting of the blood. He will study 
the changes that take place when blood coagula- 
tion factor 10 is activated. Dr. Peden is instructor 
in medicine and preventive medicine. 

Special Gifts 

The Division of Neurosurgery of Washington 
University School of Medicine, St. Louis has re- 
ceived a gift of $100,000 from the Allen P. and 
Josephine B. Green Foundation. The gift will be 
used to support basic research on the nervous 
system, Dr. Henry G. Schwartz, professor of neu- 
rosurgery, said. Under investigation will be fun- 
damental problems of the central nervous system 
that might bear on Parkinsonism, cerebral palsy 
and allied diseases. The Green Foundation of 
Mexico, Mo., has been active in support of re- 
search in the neurosurgery division for several 
years. 

Mr. Edward Mallinckrodt Jr., St. Louis phi- 
lanthropist, has given $51,000 to Washington Uni- 
versity School of Medicine for construction and 
equipping of laboratory facilities within City 
Hospital No. 1. The facilities will be used by 
Washington University faculty members who de- 
vote full-time to teaching and research at City 
Hospital. This is the first gift of a private in- 
dividual to a city hospital in St. Louis for the 
construction of research facilities. 

“We are pleased and honored that Mr. Mallin- 
ckrodt should make us a gift for this purpose,” 
Dr. Edward W. Dempsey, dean of the Medical 
School, said in announcing the gift. “The de- 
velopment of excellent teaching services in our 
hospitals is necessary if St. Louis is to maintain 
its leadership in medicine. This gift will allow us 
to assist the city in improving the training of 
residents and interns by providing facilities in 


reduce 

or obviate 
the need for 

transfusions 
and their 
attendant 
dangers 



KOAGAMIN is indicated whenever 
capillary or venous bleeding 
presents a problem. 
KOAGAMIN has an outstanding 
safety record in 25 years of use 
no report of an untoward reaction 
has been received ; however, 
it should be used 
with care on patients 

with a predisposition 


emostat 

contains:' 5 mg. oxalic acid, 2.5 mg. malonic 
acid, phenal 0.25%; sodium carbonate as buffer. 

Complete data with each 1 Occ vial. Therapy chart on request. 


CHATHAM PHARMACEUTICALS, INC. 

Newark 2, New Jersey 
Distributed in Canada by Austin Laboratories, Ltd. • Paris, Ontario 


154 


MISCELLANY 


Missouri Medicine 
February, 1964 


which the medical staff can carry out independ- 
ent research/’ 

Mr. Mallinckrodt has been active in support of 
the Medical School for many years. He has re- 
cently given funds for expansion of the Edward 
Mallinckrodt Institute of Radiology, named for 
his father, and for the support of the Division of 
Anesthesiology. 

The new laboratory facilities will be used by 
Dr. Gerald Perkoff, the university’s chief of ser- 
vice at City Hospital and associate professor of 
medicine, and other faculty members who will 
be named soon to the staff. There will be also 
facilities for medical student research projects. 

Included in the project will be a muscle dis- 
ease research laboratory, a metabolic laboratory, 
a coagulation laboratory and two general bio- 
chemical rooms. This will furnish space for four 
investigators. The Medical School hopes even- 
tually to have six to eight full time physicians 
located at City Hospital. Work on the four lab- 
oratories totaling 2,800 square feet is expected 
to be completed by March. 

There has been an affiliation between Wash- 
ington University School of Medicine and City 
Hospital for more than 30 years. The University 
medical service has had a full-time director since 


1959. Third year medical students spend six 
weeks at the hospital attending patients on the 
medical wards and additional time attending sur- 
gery patients. There are other University services 
in other specialties. 

Scott Award 

Dr. Oliver H. Lowry, professor and head of 
the department of pharmacology of Washington 
University School of Medicine, St. Louis, has re- 
ceived a John Scott award. The award, which is 
given by the Board of City Trust of Philadelphia, 
will be presented at a meeting of the American 
Association for the Advancement of Science in 
Cleveland. 

Dr. Lowry is one of four scientists from this 
country, Italy and England to receive the award 
this year. 

The award, which consists of a copper medal, 
a scroll and $2,000, was established 147 years ago 
by John Scott, a chemist of Edinburgh, Scotland. 
It is awarded to “ingenious men and women who 
make useful inventions.’’ 

Dr. Lowry received the award for a method 
of isolating, preparing, weighing and chemical- 
ly studying single nerve cells and subcellular 
particles. 


when the liver 
is threatened or 
damaged by fat 

in 

cirrhosis 

alcoholism 

hepatitis 

obesity 

diabetes 


ETH 






Volume 61 
Number 2 


MISCELLANY 


155 


UNIVERSITY OF MISSOURI 
Trips and Talks 

Dr. James A. Green, associate professor of the 
Department of Anatomy at the University of 
Missouri Medical Center, spent from December 
13 to 21 in Mexico City. The trip was made to 
collect research material and to consult with Dr. 
Manuel Maqueo. Dr. Maqueo and Dr. Green 
have been carrying on a collaborative study of 
the human ovary for two years. 

Dr. Jerry W. Brown, associate professor of the 
Department of Anatomy, attended a meeting of 
the Association for Research in Nervous and 
Mental Diseases, held in New York City on De- 
cember 6 and 7. About 400 neuroanatomists, neu- 
rologists, neurosurgeons, psychiatrists and psy- 
chologists attended the meeting. 

Dr. J. M. Martt, associate professor in the De- 
partment of Medicine and director of the Heart 
Station at the Medical Center, addressed the 
local AAGP at St. Francis Hospital in Washing- 
ton, Mo., on January 7. The topic of discussion 
was the use of cardiac pacemakers and the de- 
fibrillator. 

Dr. Richard M. Hyde, assistant professor of 
Microbiology at the Medical Center, attended a 


meeting of the National Cancer Institute in 
Washington, D. C., on December 2. He gave a 
report on the progress made in the University 
laboratory on methods of detecting immunologic 
tolerance. 

Dr. Donald Durand, assistant professor in the 
Department of Microbiology, attended a meeting 
of the Missouri Branch of the American Society 
for Microbiology in St. Louis on November 23. 
The meeting was held at the Research Center 
Building, Monsanto Chemical Company. 

Dr. Herbert S. Goldberg, professor of micro- 
biology, presented a paper entitled “Leptospi- 
rosis in Random and Select Populations” Novem- 
ber 14 at a Kansas City American Public Health 
Association meeting. Coauthors of the paper are 
Dr. D. Blenden, assistant professor of veterinary 
bacteriology, and Dr. J. T. Logue, clinical assist- 
ant professor of medicine. On November 5 Dr. 
Goldberg lectured in the Stephens College, Co- 
lumbia, “Science Seminar” via the “Tele-lecture 
Series.” The talk was heard by six universities 
around the country via telephone transmission. 
Questions and answers were exchanged. The 
subject of the talk was “Competitive Molecules- 
Antimetabolites.” Dr. Goldberg also attended a 
meeting of the Missouri Branch of the American 



mmf 



L 


... the original, complete 
lipotropic formula together with a low fat, moderate 
protein diet, helps to prevent and treat fatty 
infiltration and fatty degeneration of the liver, and 
consequent cirrhosis by helping to. . . 


remove 
liver size and 



fat and thus reduce 
to fibrosis 


contribute to increased phospholipid 
turnover and regeneration of new liver cells 


The suggested daily therapeutic dose of 9 Methischol capsules or 
3 tablespoonfuls of Methischol syrup provides: 

CHOLINE DIHYDROGEN CITRATE* 2.5 Gm. 

d! r METHIONINE 1.0 Gm. 

INOSITOL 0.75 Gm. 

VITAMIN B 12 18 meg. 

LIVER CONCENTRATE AND DESICCATED LIVER** . . 0.78 Gm. 

♦Present in syrup as 1.14 Gm. Choline Chloride 
** Present in syrup as 1.2 Gm. Liver Concentrate 

capsules: 100, 250, 500, 1000; syrup: 16 oz. and 1 gallon 

Samples of METHISCHOL and literature available from 

ii- s. vitamin a nharmac^utical cornoration 


156 


MISCELLANY 


Missouri Medicine 
February, 1964 



Protects your 
angina patient 
better than 
vasodilators alone 

‘Miltrate’ contains both pentaerythritol 
tetranitrate, which dilates the patient’s 
coronary arteries, and meprobamate, 
which relieves his anxiety about his con- 
dition. Thus ‘Miltrate’ protects your angi- 
na patient better than vasodilators alone. 

Pentaerythritol tetranitrate may infre- 
quently cause nausea and mild headache, 
usually transient. Slight drowsiness may 
occur with meprobamate and, rarely, al- 
lergic reactions. Meprobamate may in- 
crease effects of excessive alcohol. Con- 
sider possibility of dependence, particu- 
larly in patients with history of drug or 
alcohol addiction. Like all nitrate-con- 
taining drugs, ‘Miltrate’ should be given 
with caution in glaucoma. 

Dosage: 1 or 2 tablets before meals and at bed- 
time. Individualization required. 

Supplied: Bottles of 50 tablets. 

CML-9646 

Miltratef 

meprobamate 200 mg.+ 
pentaerythritol tetranitrate 10 mg. 

WALLACE LABORATORIES / Cranbury, N. /. 


Society for Microbiology at St. Louis on Novem- 
ber 23. He presided as president of the Missouri 
Branch. He also presided at a Section on Diag- 
nostic Procedures at Leptospirosis Research Con- 
ference on December 3 through 5 in Chicago, 111. 

Dr. Frank B. Engley Jr., professor and chair- 
man of the Department of Microbiology at the 
Medical Center, attended the national meeting 
of the American Public Health Association in 
Kansas City November 11 through 15 and the 
Missouri Branch meeting of the American Soci- 
ety for Microbiology in St. Louis on November 
23. He also attended a joint meeting of Missouri 
Public Health Association and Missouri Associa- 
tion of Social Welfare in Jefferson City 7 , Decem- 
ber 1, and presented lectures at St. Louis College 
of Pharmacy on December 10 and 12. 

Dr. David G. Hall, professor and chairman of 
the Department of Obstetrics and Gynecology 
at the University Medical Center, presented a 
lecture entitled “Stimulation of Labor” at a meet- 
ing of the St. Charles County Medical Society 
in St. Charles, Mo., on November 26. 

Dr. Robert E. Froelich, assistant professor of 
psychiatry, presented a paper and entered into 
open discussion at a meeting of State and Pro- 
vincial Health Authorities of North America in 
Kansas City on November 9. The topic of dis- 
cussion was the problems facing medical practice 
today and what public health’s role can or should 
be in assisting the practicing physician to meet 
these problems. 

Dr. John A. Buesseler, professor and chief of 
Ophthalmology, presented a postgraduate course 
entitled: “Ophthalmic Radiology: Diagnosis" at 
the Annual Meeting of the American Academy 
of Ophthalmology and Otolaryngology on Octo- 
ber 21. Dr. Buesseler was a guest speaker for the 
85th Annual Meeting of the Montana Medical 
Association on September 12. The subject of dis- 
cussion was “Tissue Banking and Surgical h ti- 
lization of Homografts.” He was also a guest 
speaker for the Montana Academy of Oto-Oph- 
thalmology, Billings, Mont., where he presented 
two talks: a) “Organizational and Operational 
Significance of Eye Tissue Banking to the Prac- 
titioner,” and b) “The Utilization of Fresh and 
Preserved Homologous Tissue in Ophthalmology 
and Otolaryngology.” 

Dr. Hugh E. Stephenson Jr., professor of the 
Department of Surgery, attended a Founding 
meeting of Thoracic Surgery Society 7 held in San 
Francisco, Calif., and a meeting of the American 
College of Surgeons in San Francisco. 



Contents for March 1964 


Scientific Articles: 

Intracardiac Electrograms in Congenital 
Heart Disease, Manfred Thurmann, 


M.D.; J. Gerard Mudd, M.D., and J. G. 
Janney Jr., M.D., St. Louis .... 175 

Autoimmune Disease and Thyroid Auto- 
antibodies, Benje Boonshaft, M.D., St. 

Louis 182 

Intestinal Obstruction Following Anasto- 
mosis With the Bankin Clamp, Eugene 
T. Dmytryk, M.D., St. Louis . . . 190 


Special Article: 

Some Thoughts on the New Community 
Health Centers Program, Margaret C. L. 


Gildea, M.D., St. Louis 194 

Departmental Features: 

Washington 166 

Across Missouri 168 

Missouri Academy of General Practice . 170 

Woman’s Auxiliary 172 


Uncertified Correctional Birth Records Dis- 
continued 192 

President’s Message 198 

Editorial 199 

Ramblings of the Field Secretary . . 200 

News— Personal and Professional . . . 202 

Time and Place of Meetings .... 204 

Missouri State Medical Association Program 208 

Delegates 212 

Missouri State Medical Technologists Pro- 
gram 216 

Exhibitors at the Annual Session . . . 217 

County Society News 218 

New Members 226 

Deaths 227 

Financial Statement 228 

From the Medical Schools 230 

Missouri Medicine in Review .... 238 


Information for Contributors 


Articles are accepted for publication on condi- 
tion that they are contributed solely to this jour- 
nal. Material appearing in Missouri Medicine is 
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arranged at the end of the article in the order in 
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reference should give name of author, title of ar- 
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ings in India ink on white paper. They should 


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ceived prior to the first of the month preceding 
month of publication. 

Please give notice of change of address at least 
one month in advance of the change, giving old 
and new addresses. 


165 



Federal Medical Care Program 

Proposal Burden to Social Security Taxpayers. 

This was the heading of a release of the state- 
ment made by Mr. Edward Staples, Executive 
Director of Missouri Public Expenditure Survey 
before the U. S. House Ways and Means Com- 
mittee. 

His statement in part follows: 

When our social security system was first estab- 
lished, the tax rate on employees and employers 
was 1 per cent each, applicable to a taxable wage 
base of $3,000. Since that time, including the in- 
crease which became effective on January 1, 1963, 
the tax rate has been increased seven times, until 
at present the rate is 3% per cent on both employee 
and employer. Under existing law two additional 
rate increases are scheduled, in 1966 and 1968. 
These will bring the social security tax rate on em- 
ployees and employers to 4 % per cent each — or to a 
combined rate of 9 % per cent. 

In addition, it should be noted that the taxable 
wage base against which this tax is applied has also 
increased three times, and at present stands at $4,800. 

In short, the tax paid by employee and employer 
combined has increased almost six-fold, from a max- 
imum of $60 at the inception of the program to a 
maximum of $348 under present tax rates and tax- 
able wage base. 

The tax paid by the self-employed, of course, has 
been maintained at one-and-a-half times that of 
other workers — and presently is at a rate of almost 
5/2 per cent. 

Under the bill before this committee, H.R. 3920, 
the tax rate would be increased by 14 of one per cent 
each on employees and employers, over and above 
the currently scheduled increases, and the taxable 
wage base against which the tax would apply would 
also be increased, to $5,200. Thus, if this proposal 
were to be enacted, on top of presently scheduled 
tax rate increases, the combined rate on employee 
and employer in 1968 would be 9 % per cent on an 
enlarged tax base. 

The social security tax is, in short, becoming an 
increasingly burdensome tax for a growing number 


of persons. For the low income wage earner, such 
increases in the social security tax might wipe out — 
or more than wipe out — any benefit which he would 
derive from the pending tax reduction bill. . . . 

Another factor which in my view should be taken 
into consideration is the history which has been de- 
veloped over the years for expanding the coverage 
and increasing the benefits under this program. On 
at least eight occasions since this program went into 
effect, Congress has enacted amendments expanding 
coverage to new groups, and benefit increases have 
also been approved on a number of occasions. 

That this has had some effects upon the program’s 
financial status seems apparent. The record indicates 
that expenditures have exceeded receipts in the Old 
Age and Survivors Insurance Trust Fund in five of 
the last seven years. 

Further, one of the most recent additions to the 
social security structure, the disability benefit pro- 
gram, appears to be in some trouble. Expenditures 
from the disability insurance trust fund exceeded 
receipts into the fund in calendar 1962, and accord- 
ing to official reports, as I read them, were expected 
to do so again in 1963, this year, and in each of the 
next three years. The fund’s trustees have made a 
proposal designed to put it on firmer financial foot- 
ing. In this same connection, we have noted the pro- 
posal of Chairman Mills (H.R. 6688) which is de- 
signed to improve the actuarial status of the trust 
funds by raising the amount of taxable income for 
social security from the present $4,800 to $5,400. 
This measure, as I understand it, would also allot a 
proportion of the increased social security revenues 
to the disability fund. 

Thus, we see the occasion arising for increased 
social securitv tax pavments even without adopting 
H.R. 3920. 

“I believe it is fair to indicate that the pending 
proposal to establish a compulsory health insurance 
program under social security would provide for 
limited health benefits. If adopted, the H.R. 3920 
program would be subjected to great pressures for 
further expansion. Experience under our social se- 
curity system shows repeated broadening of its pro- 
visions, accompanied by rate increases, as I have 
already indicated. Demands could be expected to in- 
clude larger and larger segments of the population 
under the medical care provisions, with each ex- 
pansion accompanied or followed by rate increases, 
until virtually the entire population would be in- 
cluded. Thus, H.R. 3920 is a foot-in-the-door type 
of proposal. It inevitably would lead to much higher 
social security tax rates on employees, employers 
and the self-employed. . . . 


166 



Special cough formula for children 

Pediacof 

Each teaspoon (5 ml.) contains codeine phosphate 5 mg., 

Neo-Synephrine® hydrochloride (brand of phenylephrine hydrochloride) 2.5 mg., 
chlorpheniramine maleate 0.75 mg. and potassium iodide 75 mg. 

soothing decongestant and expectorant 



bright red, 
pleasant-tasting, 
raspberry-flavored syrup 


Pediacof is different. It is designed espe- 
cially for children, and each ingredient is in 
the right proportion. The potassium iodide 
in Pediacof is so well masked that it is virtu- 
ally unnoticeable. Children like the sweet 
raspberry flavor of bright red Pediacof. 

Dosage: Children from 6 months to 1 year, 
Va teaspoon; from 1 to 3 years, Vz to 1 tea- 
spoon; from 3 to 6 years, 1 to 2 teaspoons; 
and from 6 to 12 years, 2 teaspoons. These 
doses are to be given every four to six hours 
as needed. 


How supplied: Bottles of 1 6 fl. oz. 


Available on prescription only. 
Exempt Narcotic. 


Side effects: The only significant untoward 
effects that have occurred are mild anorexia 
and an occasional tendency to constipation. 
However, discontinuance of Pediacof has 
seldom been required. Mild drowsiness oc- 
curs in some patients but, when cough is 
relieved, the quieting effect of Pediacof is 
considered beneficial in many instances. 

Precautions and contraindications: Patients 
with tuberculosis or those who are known 
to be sensitive to iodides should not be given 
Pediacof. 

Caution should be exercised if Pediacof is 
administered to patients with cardiac dis- 
orders, hypertension or hyperthyroidism. 

Warning: May be habit forming. 

Winthrop Laboratories 
New York, N.Y. 


Winfhrop 



Mental Health Planning Program Established 

A Comprehensive Mental Health Planning Pro- 
gram has been established in Missouri. Directing 
the program will be Edwin F. Gildea, M.D., St. 
Louis. An executive committee to assist will 
consist of Vernon E. Wilson, M.D., Columbia; 
H. M. Hardwicke, M.D., Jefferson City; George 
A. Ulett, M.D., Jefferson City; Hubert Wheeler, 
Jefferson City, Commissioner of the Department 
of Education; C. Rouss Gallop, Jefferson City, 
Director of the Department of Public Health 
and Welfare, and Ray McIntyre, St. Louis, 
MSMA, and Chairman of the Missouri Health 
Council. 

The purpose of the program is to develop a 
comprehensive plan through a cooperative ef- 
fort between the public and private health, edu- 
cational and medical organizations. It is expected 
that various mental health efforts such as pre- 
ventive programs, hospital programs, therapeutic 
programs and community health programs can 
be coordinated. 

State Board of Healing Arts Hears 
Advertising Charge 

“A case which could have far-reaching impli- 
cations on medical advertising ethics was taken 
under advisement by the Board of Healing Arts,” 
according to the St. Louis Globe-Democrat on 
January 27. 

“The seven member body heard charges 
brought against Dr. Virgil A. Bittiker, an Excel- 
sior Springs osteopath. He is accused of advertis- 
ing in certain national magazines allegedly in a 


quest for patients. Dr. Bittiker is connected with 
the Excelsior Medical Clinic, Inc. 

“Dr. William D. Perry of St. Louis, chairman 
of the board, said no decision in the case is ex- 
pected before the board’s next meeting in March. 
He said the decision to be rendered is an im- 
portant one with ‘far-reaching implications.’ At- 
torneys for both sides in the case have been di- 
rected to prepare written briefs for the board. 

“The board regulates the licensing of physi- 
cians. Dr. Perry said it could revoke Dr. Bittiker’s 
license if charges against him prove to be true.” 

Drugs Under New Law Discussed 

The Medical Advisory Committee to the Divi- 
sion of Welfare met in January and received a 
report concerning the present status of the re- 
cently inaugurated drug and dental program for 
persons receiving Old Age Assistance and Aid to 
the Permanently and Totally Disabled. 

Legislation enacted by the 72nd General As- 
sembly, which became effective last October, 
provided for certain drugs and dental services 
for the aged and disabled. Proctor N. Carter, 
Director of the Division of Welfare, reported 
that at the present time there are 843 drug stores 
participating in the program, that 735 dentists 
are participating and that 54 physicians who dis- 
pense drugs, principally in areas where there 
are no pharmacies, also are cooperating. He said 
that there are no pharmacies in Scotland, Osage, 
Maries, St. Clair and Hickory but that three of 
the counties have physicians who dispense drugs. 

Senator William J. Cason, Chairman of the 
Senate Committee on Public Health and Welfare 
and a member of the Advisory Committee, asked 
Mr. Carter to submit a report early in March as 
to the status of the program and money to finance 
it so that a decision could be made as to expan- 
sion of the services. 

Large Number Get First and Second 
Polio Vaccine 

An unexpected number of persons, estimated 
at 625,000 received their first or second polio 
vaccine dosage at 174 clinics in St. Louis and St. 
Louis County and 31 in St. Clair Count} 7 (Illi- 
nois) the last Sunday in January. 

A similar series of clinics were held in that 
area in November but the number attending the 
second one indicated that many were receiving 
their first dose. Another clinic is planned for 
later if it appears that many received their first 
dose at the January clinic. 


168 


ADVERTISEMENTS 


169 



an easier way? 


‘methedrine: 

METHAMPHETAMINE HYDROCHLORIDE 

is an easier way to help control food craving & keep the reducer happy 


With “hunger pains” abolished, the patient can 
shrug off the chains of psychogenic craving 
that bind him to his habit of overeating and 
cooperate cheerfully with the prescribed diet. 

In obesity, “...our drug of choice has been 
methedrine (methamphetamine hydrochlo- 
ride)... because it produces the same central 
effect with about one-half the dose required 
with plain amphetamine, because the effect 
is more prolonged, and because undesirable 
peripheral effects are significantly minimized 
or entirely absent.” Douglas, H. S.: West. J. 
Surg. 59:238 (May) 1951. 


Description: Each scored tablet contains 5 mg. 
‘Methedrine’ brand Methamphetamine Hydrochloride. 

Dosage: 2.5 mg. ( 1/2 tablet) 3 times daily. May be in- 
creased gradually according to response; more than 
10 mg. daily rarely is needed. The last dose of the day 
should not be taken later than 6 hours before bedtime. 

Side effects: Insomnia may occur if taken later than 6 
hours before retiring. The usual peripheral actions of 
sympathomimetic amines (vasoconstriction and accel- 
eration of the heart) are minimal and little noticed on 
low or moderate dosage. 

Contraindications and precautions: Should not be used 
in patients with myocardial degeneration, coronary dis- 
ease, marked hypertension, hyperthyroidism, insomnia 
or a sensitivity to ephedrine-like drugs. Moderate hyper- 
tension in the obese is not necessarily a contraindication 
since it may be relieved as the overweight is reduced. 

Supplied: Tablets 5 mg., scored, in bottles of 100 and 

1000. 


Complete literature available on request from Professional Services Dept. PML. 

BURROUGHS WELLCOME & CO. (U.S.fl.) INC.,Tuckahoe, N.Y. 



C. G. STAUFFACHER, M.D., Secretary 


Missouri Academy of General Practice 


A board meeting of the MAGP was held at the 
Missouri Hotel in Jefferson City on Sunday, Jan- 
uary 19, with Chairman Walter T. Gunn of St. 
Louis presiding. Reports were received from var- 
ious committees, namely: Education, Member- 
ship, Public and Professional Relations, Mental 
Health, Publication, National Defense and Fi- 
nance. 

Actions taken by the Board included: 

Voted six active members to active-exempt 
membership status; voted to reelect for another 
three year membership period three members on 
the basis of satisfactory study credits submitted; 
voted to drop two members for failure to submit 
satisfactory postgraduate study credits; voted to 
membership eight applicants, including five for 
active and three for associate. The Board ap- 
proved Public and Professional Relations Com- 
mittee participation in a luncheon and program 
for the junior medical students at the University 
of Missouri on May 20, during the Spring Clinical 
Conference at M. U. Medical School. 

They voted to convene the 1965 Annual Scien- 
tific Assembly of the Missouri Academy in St. 


Louis and the 1966 assembly in Kansas City. 

They took under consideration a proposed 
resolution to be presented at the 1964 AAGP 
Congress of Delegates meeting which would 
amend the new “1964 definition of acceptable 
continuation study credits” adopted at the 1963 
AAGP Annual Session and became effective Jan- 
uary 1, 1964; also voted to hold the next board 
meeting in Columbia on Wednesday night, May 
20. 

A number of speakers have already accepted 
invitations to appear on the two-day Annual Ses- 
sion Program of the MAGP to be held at the 
Chase Hotel, in St. Louis, on Saturday and Sun- 
day, October 31 and November 1, 1964. 

Academy President Edson C. Carrier of Kan- 
sas City informed the Board that the featured 
speaker for the President’s Installation dinner 
meeting on Saturday night, October 31, will be 
Richard C. Bates, M.D., Lansing, Michigan. His 
subject will be, “How to Have a Heart Attack.” 
Dr. Bates makes over a hundred speeches a year 
throughout the United States and this topic is a 
favorite one. 



Give now . . . 

to your 

medical student 
‘ loan fund 
• Help deserving 
young Missourians! 


Missouri State Medical Foundation 

634 Missouri Theatre Bldg. / Saint Louis 3, Missouri 
SPONSORED BY THE MISSOURI STATE MEDICAL ASSN. 


170 


ADVERTISEMENTS 



the bronchodilator 
with the intermediate dose of KI 


combination of the four most widely used drugs for treatment of 
asthma. Each tablet contains Aminophylline 130 mg., Ephedrine 
HC1 16 mg., Phenobarbital 22 mg. (Warning: May be habit forming), 
Potassium Iodide 195 mg. — compounded for prompt absorption and 
balanced action, and buffered for tolerance. 

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Woman’s Auxiliary 



Recently, I received a reprint of an article on 
“Medical Education Loans” from the January 4 
Journal of the AMA. There has been some con- 
cern this year as to what effect the Health Pro- 
fessions Educational Assistance Act of 1963, PL 
88-129, would have on AMAERF. The article 
answers some of the questions that have been 

raised. A total of 11,500 
commercial bank loans for 
medical students, interns 
and residents have been 
secured and nearly $14 
million has been loaned 
with a demand of nearly 
20 per cent more over the 
comparable period of the 
previous year. 

The report emphasized 
the current need for ad- 
ditional funds for the 
AMAERF and outlined the difference between 
the two programs. Under the federal loan pro- 
gram, capital is provided for loans to students of 
dentistry, medicine and osteopathy and the 
money must be paid back within three years 
following completion of school; schools are re- 
quired to put up $1 for every $9 allocated by the 
government and are responsible for collections; 
the maximum loan is $2,000 a year and a school 
shall give preference to persons who enter as a 
first year student; and finally, the funds cannot 
be used in combination with those of the Na- 
tional Defense Education Act. 

AMAERF loans money to medical students, 
interns and residents up to $1,500 a year and 
up to $10,000 for an entire training period 
with no payments required until five months 
after completion of all full-time training, includ- 
ing internship and residency; medical schools 
and hospitals are not required to put up match- 
ing funds or to make collections. Though the 
federal program charges less interest, the big 
difference is that the taxpayer pays the bill. 
“Medical students must undergo a long and dif- 
ficult training period. At the end of that period, 


however, they have every prospect of earning 
an above-average income. The AMA believes 
that they are thereby well equipped to borrow 
as responsible individuals and without public 
subsidy. This belief is the cornerstone of the 
AMAERF Loan Program and it will remain firmly 
in place.” 

This year, under the national theme of “Serve 
and Communicate” our auxiliaries have compiled 
an enviable record of accomplishment. Almost 
every group has made a special effort to prove 
their concern for their communities in some way. 
As in other years, a cup will be awarded at the 
convention to the auxiliary that has earned the 
most points. Out convention guests will be Mrs. 
C. Rodney Stoltz, the National President, and 
Mrs. Paul Gray, President of the Southern Aux- 
iliary, who will both bring greetings. 

A great many people are responsible for the 
success of this year. My officers, directors, com- 
mittee chairmen, county presidents and other 
appointees have all been most helpful; the Past 
Presidents have given invaluable guidance and 
counsel; the MSMA staff has cooperated in every 
way possible; and we are especially indebted to 
the president of MSMA, Dr. Kenneth C. Holl- 
weg, and to the other Medical Advisors, Dr. Dur- 
ward G. Hall, Dr. J. Martyn Schattyn, Dr. W. 
Russell Smith and Dr. Vernon E. Wilson, for 
their interest and understanding. I am grateful 
to all of these people and to all of the members 
for their support. 

In a few days, I shall turn the gavel over to 
my successor, Mrs. Delevan Calkins of the St. 
Louis City Auxiliary. Everyone will appreciate 
her friendliness, warmth and charm as well as 
her ability to administer Auxiliary affairs. I know 
Bitsy will receive the same wonderful coopera- 
tion and loyalty that I have. 

It has been a pleasure to serve as president of 
the Auxiliary— not always easy, but always a 
challenge and now a most cherished memory of 
the fine women throughout the state who con- 
tributed their time and thought in so many ways 
to the record of my year. Thank you. 



Mrs. L. S. Crispell 


172 




Volume 61, Number 3 — March, 1964 


Missouri Medicine 

JOURNAL OF THE MISSOURI STATE MEDICAL ASSOCIATION 

Copyright, 1964 by Missouri State Medical Association. All Rights Reserved. 


MANFRED THURMANN, M.D.; J. GERARD MUDD, M.D., 
and J. G. JANNEY JR., M.D., St. Louis 


Intracardiac Electrograms in 
Congenital Heart Disease 


An investigation to determine whether in- 
tracardiac electrograms are of value in the 
differential diagnosis of congenital heart 
disease is reported. The work was supported 
by the Missouri Heart Association. 

Dr. Thurmann was Research Fellow of 
the Missouri Heart Association; Dr. Mudd is 
Associate Professor of Medicine, and Dr. 
Janney is Associate Professor of Clinical 
Medicine, all at St. Louis University School 
of Medicine. 


Intracardiac electrography has been used to 
study the normal activation of the heart, 1 ’ 2 right 
and left bundle branch block, 3, 6 the Wolff-Park- 
inson-White Syndrome 7 and supraventricular and 
ventricular arrhythmias. 8 Only a few studies 
have dealt with congenital heart diseases, 1, 10 the 
most contributory being in the diagnosis of Eb- 
stein’s anomaly. 11 The purpose of this investiga- 
tion is to determine whether intracardiac electro- 
grams are of value in the differential diagnosis 
of congenital heart disease. 

Material and Methods 

Intracardiac electrograms were obtained on 50 
patients by right heart catheterization. Their 


average age was 9.4 years ranging from 2 weeks 
to 56 years ( table 1 ) . 

The intracardiac electrographic procedure was 
carried out immediately after the standard right 
heart catheterization and cineangiography. Pres- 
sures and standard electrocardiograms were re- 

TABLE 1 

AGE OF PATIENTS CATHETERIZED 


Age No. of Pts. 


Under 6 mos 13 

6 mos. to 1 yr 4 

1- 5 yrs 11 

5-10 yrs 9 

11-20 yrs 5 

21-30 yrs 4 

30-60 yrs 4 

Total 50 


corded and used for comparison. A number 5 
Cournand electrode-catheter was introduced into 
the heart through the saphenous vein. The posi- 
tion of the catheter was confirmed at each trac- 
ing taken by fluoroscopic observation, pressures 
and saturations. Electrograms were taken with 
the catheter in five locations: low right atrium at 
the level of the diaphragm, mid right atrium, 
high right atrium near the superior vena cava, 


175 


176 


INTRACARDIAC ELECTROGRAMS— THU RM ANN ET AL. 


Missouri Medicine 
March, 1&64 


mid left atrium and right ventricle. Pullback trac- 
ings were often obtained on withdrawal of the 
catheter from the right ventricle or left atrium 
into the right atrium. 

A Sanborn Twin Viso electrocardiographic di- 
rect writer was utilized for recording, one chan- 
nel for the intracardiac electrogram and the sec- 
ond for standard lead III. All the electrograms 
were standardized in the usual manner. 

The nomenclature used to describe the com- 
ponents of the atrial electrogram is that advo- 
cated by Hecht, 12 which consists of placing a 
P before the letters indicating the positive and 
negative deflections. Small and capital letters are 
used according to the relative magnitude of the 
deflections, thus Pqrs, PRS. 

Any of the following constituted standard elec- 
trocardiographic criteria for the diagnosis of 
right ventricular hypertrophy: an R in Vi of 7 
mm. or more, an S in Vi of 2 mm. or less, an R/S 
ratio in Vx of more than 1, a total of R height in 
Vi plus S depth in V 5 or Vo of more than 10.5 
mm. and/or the presence of a right axis devia- 
tion. 15 

Left atrial enlargement was diagnosed when 
the frontal P vector was greater than its normal 
average orientation of +60°, the P waves in I 
and AVL were of more than 0.11 sec. duration 
with a double-peaked or flattened summit and/or 
large biphasic or downwardly directed P waves 
were present in Vi and V 2 . 3, 15 

Right atrial enlargement was considered to be 
present when the frontal P vector was less than 
its average normal orientation of --60° and/or 
tall, peaked P waves of 2.5 mm. amplitude or 
more were seen in leads II, III and AVF. 3, 15 

The largest deflections of the electrocardio- 
graphic complexes were measured in millimeters 
in the different locations. 

The following data were analysed: 

a. Configuration and amplitude of the QRS 
complex in the right ventricle. 

b. Configuration and amplitude of the P and 
QRS complexes in the atria. 

c. Abnormalities of the PTa (auricular T wave) 
and ST segments. 

d. Arrhythmias. 

e. Relationship between standard elctrocar- 
diographic diagnosis of right artial enlargement 
and atrial pressures and atrial intracavitary com- 
plexes. 

f. Relationship between standard electrocar- 
diographic diagnosis of right ventricular hyper- 
trophy and right ventricular pressures and right 
ventricular intracavitary complexes. 


Results 

Table 2 shows the diagnosis in the 50 cases 
and table 3 shows the configuration of the P and 
QRS complexes in the atria and of the QRS com- 
plexes in the right ventricle. The intracavitary 
complexes were not obtained in the left atrium 

TABLE 2 

FINAL DIAGNOSIS OF PATIENTS STUDIED 


Diagnosis 


Normal (Functional Heart Murmur) 7 

Atrial Septal Defect 5 

Ventricular Septal Defect 12 

Pulmonary Stenosis 4 

Atrial Septal Defect and Pulmonary Stenosis 2 

Atrial Septal Defect & Patent Ductus Arteriosus 1 

Aortic Coarctation 1 

Atrial Septal Defect (Ostium Primum) . 1 

Primary Pulmonary Hypertension 2 

Atrio-Ventricular Canal 1 

Ventricular Septal Defect & Pulmonary Stenosis 6 

Atrial Septal Defect, Ventricular Septal Defect and 

Pulmonary Stenosis 1 

Endocardial Fibroelastosis 2 

Ebstein’s Anomaly 1 

Partial Anomalous Venous Return into Superior Vena 

Cava 1 

Atrial Septal Defect and Total Anomalous Venous 

Return into Coronary Sinus 1 

Dextroposition with Absent Right Upper and Middle 

Pulmonary Arteries 1 

Pectus Excavatum 1 

Total 50 


and right ventricle in all patients due to tech- 
nical difficulties. As can be seen, the patterns 
obtained in the various positions of the elec- 
trode-catheter are those seen in the activation of 
normal hearts. 13, 14 

The analysis of the PTa segments and ST seg- 
ments showed an elevation of the PTa segment 
in the right atrium in seven patients and an 
elevation of the ST segment in the right ventricle 
in four patients. These changes were due to pres- 
sure of the electrode-catheter on the endocar- 
dium as they subsided immediately when the 
electrode-catheter was pulled back from the 
place at which it was pressing on the endocar- 
dium. Simultaneous changes of the ST and PTa 
segments were not seen in standard lead III. 
These changes were produced accidentally and 
no attempt was made to produce them in the 
other patients studied. 

The following arrhythmias were observed: one 
patient had one atrial premature contraction 


Volume 61 
Number 3 


INTRACARDIAC ELECTROGRAMS— THURM ANN ET AL. 


177 


TABLE 3 

TYPES OF INTRACARDIAC COMPLEXES 



Atrial 
Complexes 
in R.A. 

LOW MID HIGH 

Ventricular 
Complexes 
in R.A. 

LOW MID HIGH 

Atrial 
Complexes 
in L.A. 

Ventricular 
Complexes 
in L.A. 

Ventricular 
Complexes 
in L.A. 

PRs 

. . 4 






2 



PRS 

. . 2 

4 

8 




4 



Prs 

26 

9 

3 




2 



PrS . 

. . 7 

27 

11 




7 



Pr 

. . 7 

1 

1 




2 



PQS 

4 

8 

25 




1 



Prsr . . . 


1 

1 







PqR 



1 







rSR . . 




7 

9 

17 


1 

2 

rSRS . . 




1 


1 




rSr 




5 

6 

3 


1 

3 

rS 




4 

2 

4 


7 

25 

rSrr . . . 




1 

2 

1 




rSRs 




1 






qR 




6 

9 

4 


1 


QR 




17 

7 

10 


3 


Qr 




2 

7 

5 




QS .... 




3 

6 

4 


2 


qrr ... 




1 

1 

1 




qrSr 




1 

1 





Qrs 




1 




1 


qRS 








2 


RS . . 









4 

rsrs . . . 









1 

Total 

50 

50 

50 

50 

50 

50 

18 

18 

35 


RA = right atrium 
LA = left atrium 
RV = right ventricle 


( APC ) with the catheter in the right atrium and 
one patient developed a run of six with the 
catheter in the same location. One patient had 
one APC while pulling back the catheter from 
the left atrium to the right atrium and one APC 
was produced in another patient while pulling 
the catheter back from the right ventricle to the 
right atrium. 

Nine patients developed ventricular premature 
contractions (VPC). One had a short run of 
ventricular tachycardia while introducing the 
catheter into the right ventricle; one patient had 
two VPC successively and another, four VPC 
while pulling the catheter back from the right 
ventricle to the right atrium. One patient had 
two VPC successively with the catheter in the 
right ventricle. Each of these four patients had 
their arrhythmias after a short period in which 
the ST segments were elevated. The five other 
patients had one VPC while the catheter was 
pulled back from the right atrium to the right 
ventricle. 


Table 4 shows the relationship between the 
electrocardiographic diagnosis of atrial enlarge- 
ment, the mean atrial pressure, the P voltage in 
millimeters and the age of the patient. Six pa- 
tients had electrocardiographic evidence of right 
atrial enlargement. Their average right atrial 
mean pressure was 4.5 mm. Hg and their aver- 
age intracavitary P wave voltage was 15 mm. 
Forty-four patients with no evidence of right 
atrial enlargement had an average mean right 
atrial pressure of 1.9 mm. Hg and an average P 
wave voltage of 9.6 mm. The findings obtained in 
the right atrium and right ventricle bore no rela- 
tion with the age of the patient. 

Table 5 shows the relationship found between 
the electrocardiographic diagnosis, the age of the 
patient, the right ventricular pressure and the 
QRS voltage in the right atrium and ventricle. 
Right ventricular pressures above 35 mm. Hg 
were considered to be definitely above normal. 
Thirty-one patients had an average systolic right 
ventricular pressure of 73.3 mm. Hg. The aver- 


178 


INTRACARDIAC ELECTROGRAMS— THU RM ANN ET AL. 


Missouri Memcike 
March. li*64 


TABLE 4 

CORRELATION OF THE RIGHT ATRIAL PRES- 
SURES AND INTRA-ATRIAL P WAVE VOLTAGES 



WITH THE PRESENCE OR ABSENCE OF 
RIGHT ATRIAL ENLARGEMENT 

P Voltage in 

Right Atrial Mean 


Atrium ( mm.) 

Pressure ( mm. Hg) 

Age in Years 


30 

0 

10 


30 

1 

51 


27 

0 

19 


25 

1 

19 


20 

1 

7 


18 

0 

3 


17 

0 

10 


15 

3 

2/3 


14 

2 

52 


14 

3 

1/6 


12 

1 

3 

. 

12 

4 

1/6 

c 

4) 

11 

1 

1 1/2 

s 

10 

1 

10 

W) 

u 

10 

2 

25 

■a 

10 

0 

7 

<U 

8 

1 

2/3 

jot 

8 

0 

2 

03 

8 

1 

22 

pC 

8 

1 

6 



7 

0 

4 


7 

2 

2 

J3 

a 

7 

7 

3 

« 

U 

&D 

6 

4 

3 

.© 

■5 

6 

0 

13 

U 

CO 

6 

1 

11 

o 

6 

0 

1/12 

1 

6 

10 

19 

75 

6 

2 

1/2 

P 

6 

4 

5 

JS 

4-» 

5 

7 

30 

5 

5 

5 

5 


5 

2 

1/8 


5 

3 

2 


5 

1 

11/12 


4 

2 

1/6 


4 

0 

2/3 


4 

3 

22 


4 

1 

56 


4 

2 

1/12 


3 

1 

5 


3 

2 

1/6 


3 

1 

1/2 


2 

9.6 mm. 

1 

Average 1.9 mm. Hg 

1/3 


20 

1 

1/24 

o 

18 

0 

1/24 


16 

8 

20 

H M 

< 7: 

15 

9 

4 

Ph 

13 

8 

1/12 

£ 

8 

15 mm. 

1 

4.5 mm. Hg 

6 


age maximum QRS voltage in the right atrium 
was 23 mm. and in the right ventricle 54 mm. 
Thirty-one of these patients had an electrocar- 
diographic diagnosis of right ventricular hyper- 
trophy, six had incomplete right bundle branch 
block and one had complete right bundle branch 
block. 

Nineteen patients had right ventricular pres- 
sures below 35 mm. Hg, averaging 27 mm. Hg 
(table 6). The average QRS voltage in the right 
atrium in this group was 18 mm. and in the right 
ventricle was 35 mm. 

Right Atrial Complexes 

The variable morphology of the right atrial 
complexes from tracing to tracing in individual 
patients is attributed to difference in the posi- 
tion of the catheter in relation to the direction 
of the atrial depolarization and to the distance of 
the catheter tip from the sino-auricular node. 
When the catheter tip is close to the sino-auric- 
ular node the electrical impulse travels away 
from the electrode, giving, therefore, mainly neg- 
ative complexes of the PQr and PrS type. The 
configuration of the atrial complexes varied with 
the position of the catheter in the right atrium, 
but not in relation to the presence of ordinary 
electrocardiographic evidence of atrial enlarge- 
ment nor the mean atrial pressure. A direct rela- 
tionship was found between the average of the 
right atrial mean pressure and the average of the 
voltage of the intracavitary P wave, that is, the 
higher the pressure the greater the amplitude of 
the P wave and vice versa (table 4). This rela- 
tionship was not always seen in the individual 
cases. In the lower levels of the atrium the com- 
plexes were mainly of the Prs type and in many 
instances resembled the P waves obtained in 
standard lead III. 16 ' 17 

The observation 3 has been made that W shaped 
P waves in the right atrium are rarely found in 
normal cases, but usually in atrial enlargement or 
dilatation. These changes in the P waves are 
attributed to the separate activation of each atri- 
um. 3 Four of our cases had W shaped P waves, 
two had primary pulmonary hypertension, one 
with right atrial enlargement by the standard 
electrocardiogram. One patient had a coarctation 
of the aorta and the other an atrial septal defect. 

Zimmerman 18 mentions that negative deflec- 
tions often occur in the lower levels of the right 
atrium when it is hypertrophied or dilated, be- 
ing produced by the activation of the hypertro- 
phied right atrial appendage. We found four 
cases with negative atrial complexes at the low 


Volume 61 
Number 3 


INTRACARDIAC ELECTROGRAMS— THURMANN ET AL. 


179 


TABLE 5 

CORRELATION OF ECG DIAGNOSIS AND QRS VOLTAGES IN THE RIGHT ATRIUM AND VENTRICLE 
IN PATIENTS HAVING ELEVATED RIGHT VENTRICULAR PRESSURES 


ECG 

Diagnosis 

Right Ventricular 
Pressure ( mm. Hg) 

QRS Voltage ( mm.) 
Right Atrium 

QRS Voltage ( mm.) 
Right Ventricle 

Age ( yr.) 

1. RVH 

35/0 

12 

90 

2/3 

2. RVH 

IRBBB 

36/0 

15 


5 

3. RVH 

40/0 

35 


1/6 

LVH 

4. RVH 

40/0 

14 

35 

1/12 

5. IRBBB 

42/0 

8 

17 

47 

6. RVH 

50/0 

32 

50 

6 

7. RVH 

54/0 

18 


1/12 

LVH 

8. RVH 

55/0 

15 

80 

1 1/2 

9. IRBBB 

56/0 

20 

15 

4 

RVH 

10. RVH 

62/0 

13 

40 

3 

11. RVH 

62/0 

100 

54 

1/6 

LVH 

12. RVH 

62/0 

43 

48 

6 

LVH 

LAE 

13. RVH 

63/10 

25 


1/12 

RAE 

14. RVH 

65/0 

15 

80 

3 

15. RVH 

65/0 

30 

60 

3 

LVH 

16. RVH 

70/0 

30 

50 

10 

17. RVH 

70/0 

20 


1/11 

18. RVH 

72/0 

20 

50 

11 

19. RVH 

75/0 

60 

90 

1/8 

LVH 

20. IRBBB 

78/0 

12 


56 

21. RVH 

78/0 

20 

60 

1/2 

LVH 

22. RVH 

80/0 

25 

38 

8 

LVH 

23. RVH 

83/0 

10 


2 

24. RVH 

CRBBB 

85/18 

10 


19 

25. RVH 

100/0 

10 

80 

5 

26. RVH 

100/0 

20 

70 

2 

27. RVH 

101/0 

60 

70 

2/3 

LVH 

28. RVH 

105/0 

12 


18 

29. IRBBB 

108/0 

20 


1/6 

LAE 

RAE 

30. RVH 

145/0 

30 


25 

IRBBB 

31. RVH 

200/0 

Aver. 73.3 mm. Hg 

13 

Aver. 23 mm. 

Aver. 54 mm. 

30 


RVH = right ventricular hypertrophy 
LVH = left ventricular hypertrophy 
IRBBB = incomplete right bundle branch block 
WNL = within normal limits 


CRBBB = complete right bundle branch block 
RAE = right atrial enlargement 
LAE = left atrial enlargement 


180 


INTRACARDIAC ELECTROGRAMS— THURMANN ET AL. 


Missouri Meiucinr 
March, 1 >64 


level, only one of which had electrocardiographic 
right atrial enlargement. 

The most frequent ventricular complexes in 
the right atrium were of the QR, QS and rsR 
type regardless of the type of congenital heart 
disease. These are the complexes that were also 
found in the normal cases, and correspond to 
normal septal and ventricular depolarization. In 
12 cases of electrocardiographic right ventricular 
hypertrophy the complexes registered at all levels 
in the right atrium were of the QR and qRS type 
which is similar to what has been observed by 
others. 3, 18 Even though no diagnostic criteria 


Right Ventricular Complexes 

In the right ventricle the rS pattern predom- 
inated, which had been found by others. 1, 3 * 18 21 
Table 5 shows the average voltage in millimeters 
of the QRS complex in the right ventricle in 
relation to the right ventricular pressures. In in- 
dividual cases, no consistent relationship could 
be found between the right ventricular pressures 
and the voltage of the QRS complex nor with the 
electrocardiographic diagnosis, but a direct rela- 
tionship was found between the average right 
ventricular pressure and the average voltage of 


TABLE 6 


CORRELATION OF ECG DIAGNOSIS AND QRS VOLTAGES IN RIGHT ATRIUM AND VENTRICLE IN 
PATIENTS HAVING NORMAL PRESSURES IN THE RIGHT VENTRICLE 



ECG 

Diagnosis 

Right Ventricular 
Pressure ( mm. Hg) 

QRS Voltage ( mm.) 
Right Atrium 

ORS Voltage (mm.) 
Right Ventricle 

Age, Years 

1 . 

WNL 

20/0 

39 

45 

2 

2. 

RVH 

21/0 

20 

46 

11/12 

3. 

WNL 

22/0 

22 

24 

19 

4. 

WNL 

25/0 

20 

48 

2/3 

5. 

WNL 

25/0 

12 

24 

4 

6. 

WNL 

25/0 

15 

40 

5 

7. 

WNL 

25/0 

8 

40 

22 

8. 

lst° AV 






Block 

25/0 

19 

36 

3 

9. 

WNL 

26/0 

15 


7 

10. 

IRBBB 

26/0 

15 

35 

7 

11. 

RVH 

27/0 

32 


1/6 

12. 

LVH 

28/0 

27 

40 

1/2 

13. 

IRBBB 

30/0 

12 


13 

14. 

WNL 

30/0 

15 

50 

1/3 

15. 

IRBBB 

30/0 

10 


22 

16. 

WNL 

31/0 

22 

40 

3 

17. 

WNL 

32/0 

18 

29 

10 

18. 

WNL 

32/0 

20 


51 

19. 

WNL 

34/0 

10 

19 

52 



Aver. 27 mm. Hg 

Aver. 18 

Aver. 35 



could be established, which would assure the 
presence of right ventricular hypertrophy, it was 
found that the average of the right ventricular 
pressures had a direct relationship to the average 
of the QRS voltages, registered in the right atri- 
um; that is, the higher the pressure, the greater 
the voltage and vice versa. This relationship was 
not always seen in the individual cases. 

Left Atrial Complexes 

The atrial complexes registered in the left atri- 
um were similar to those seen in the middle and 
low levels of the right atrium. The ventricular 
complexes were of the QS and Qr type. 


the intracavitary QRS complex; the higher the 
pressure the greater the amplitude. Large ampli- 
tudes of the intracavitary ventricular complexes 
have been considered as evidence of right ven- 
tricular hypertrophy. 2 As can be seen, in table 
5, 13 of 28 cases, 46 per cent, with standard elec- 
trocardiographic right ventricular hy-pertrophy 
showed QRS voltages of 50 mm. or more in the 
right ventricle and four of 28 cases ( 16 per cent) 
showed QRS voltages of 40 mm. or more in the 
right atrium. QRS heights above 40 mm. in the 
right atrium and above 50 mm. in the right ven- 
tricle always correlated with right ventricular 
hypertrophy. Of 31 cases with right ventricular 


Volume 61 
Number 3 


INTRACARDIAC ELECTROGRAMS—THURMANN ET AL. 


181 


pressures, above 35 mm. Hg, 28 (90 per cent) 
showed standard electrocardiographic evidence 
of right ventricular hypertrophy. 

As observed by others, 2, 3 the pressure of the 
electrode-catheter on the endocardium produced 
elevations of the PTa segment in the atria and of 
the ST segment in the ventricle but no slurring 
of the upstroke of the P wave was detected. No 
changes were observed in the ST segment of 
the simultaneously taken lead III, indicating that 
the changes in the intracardiac recording are 
due to pressure on a small area of endocardium 
caused by the tip of the catheter. It is interesting 
to note that four cases developed short runs of 
ventricular premature contractions after the 
periods of ST elevations. In the case of Ebstein’s 
anomaly a marked elevation of the PTa segment 
was seen at the high level of the enlarged right 
atrium. The changes in the ST segment in the 
lower portion of the right atrium close to the 
misplaced tricuspid valve as reported by Her- 
nandez 11 were not seen, probably because the 
catheterization was performed through the sa- 
phenous vein and therefore no pressure was pro- 
duced on the lower portion of the large right 
atrium. 

The use of intracardiac electrography as a 
means of determining catheter position 9, 10, 14, 22 
is not of greater value than the direct fluroscopic 
observation and pressure curve determination. 

Summary 

Fifty intracardiac electrograms were analyzed 
to establish a correlation with the different types 
of congenital heart diseases. The following con- 
clusions were derived: 

1. The intracardiac electrocardiographic trac- 
ings showed the atrial and ventricular complexes 
in the different positions to be similar and not 
distinct from those found in normal hearts. 

2. No correlation could be established which 
is of value in the differential diagnosis of con- 
genital heart disease. 

3. Injury patterns were seen corresponding to 
pressure of the catheter tip on the endocardium. 
These were not seen on the simultaneous stan- 
dard electrocardiogram. 

4. Intracardiac electrography was not consid- 
ered of greater value than fluoroscopy or pres- 


sures in determining the position of the catheter 
within the heart chambers. 

5. A direct relationship was established be- 
tween the average right atrial mean pressure and 
the P voltage in the right atrium. The same rela- 
tionship was also established between the aver- 
age right ventricular pressure and the QRS volt- 
age in the right ventricle. 

6. A good correlation was found between the 
standard electrocardiogram and the data ob- 
tained with the intracardiac electrode and cath- 
eter with the routine catheterization data. 

Bibliography 

1. Bertrand, C. A. ; Zohman, L. R., and Williams, H. : Intra- 
cardiac Electrocardiogram in Man, Am. J. Med. 26:634, 1959. 

2. Zimmermann, H. A.: Intra-Vascular Catheterization, Charles 
C Thomas Publisher, Springfield, 111. p. 474-535, 1959. 

3. Sodi-Pallares, D., and Calder, R. M. : New Bases of Electro- 
cardiography, The C. V. Mosby Company, St. Louis, p. 656-616, 
1956. 

4. Sodi-Pallares, D. ; Estandia, A. ; Soberon, J., and Rodriguez, 
M. D. : The Left Intraventricular Potential of the Human Heart. 
II. Criteria for diagnosis of incomplete bundle branch block. 
Am. Heart J. 40:655, 1951. 

5. Sodi-Pallares, D. ; Thomsen, P., and Soberon, J. ; New Con- 
tributions to the Study of the Intracavitary Potential in Cases 
of Right Bundle Branch Block in the Human Heart, Am. Heart 
J. 36:1, 1948. 

6. Sodi-Pallares, D. ; Soberon, J. ; Cabrera, E„ and Vizcaino, M. : 
Estudio comparative del potencial intracavitario del hombre y en 
el perro. Arch. Inst. Cardiol. Mexico 17 :630, 1947. 

7. Zimmermann, H. A., and Scott, R. W. : Cavity Potentials of 
the Human Ventricles, Circ. 3 :1, 1951. 

8. Kossmann, C. E. ; Berber, A. R. ; Briller, S. A. ; Rader, B., 
and Brumlick, J. : Anomalous Atrioventricular Excitation Pro- 
duced by Catheterization of the Normal Human Heart, Circ. 
1:902, 1950. 

9. Datey, K. K., and Gandhi, M. J. : Intracardiac Electrograms 
at the Pulmonary Valve, Brit. Heart J. 23 :539, 1951. 

10. Watson, H. : Intracardiac Electrography in the Investiga- 
tion of Congenital Heart Disease in Infancy and the Neonatal 
Periods, Brit. Heart J. 23 :144, 1962. 

11. Hernandez, R. A. ; Rochking, R., and Cooper, H. R. : The 
Intracavitary Electrocardiogram in the Diagnosis of Ebstein’s 
Anomaly, Am. J. Card. 1 :181, 1958. 

12. Heeht, H. H., and Woodburg, L. A. : Excitation of Human 
Auricular Muscle and the Significance of the Intrinsicoid De- 
flection of the Auricular Electrocardiograms, Circ. 2 :37, 1950. 

13. Kossman, C. E. ; Berger, A. R. ; Rader, B. ; Brumlik, J. ; 
Briber, S. A., and Donnelly, J. H. : Intracardiac and Intra- 
vascular Potentials Resulting from Electrical Activity of the 
Normal Human Heart, Circ. 2 : 10, 1950. 

14. Dickerson, R. B., and Caris, T. N. : Supplemental Value 
of Intracavitary Electrocardiography in Cardiac Catheterization, 
Circ. 20:928, 1959. 

15. Massie, E., and Walsh, T. J. : Clinical Vectocardiography 
and Electrocardiography, The Year Book Publishers, Inc., Chica- 
go. p. 138-147, 195, 241-253, 1960. 

16. Cournand, A., and Ranges, H. A. : Cathetherization of the 
Right Auricle in Man, Proc. Soc. Exper. Biol. & Med. 46 :462, 
1941. 

17. Levine, H. D. ; Hellems, H. K. ; Wittenborg, M. H., and 
Dexter, L. : Studies in Intracardiac Electrography in Man. I. 
The Potential Variations in the Right Atrium, Am. Heart J. 
3 7:46, 1949. 

18. Zimmermann, H. A., and Hellerstein, H. K. : Cavity Po- 
tentials of the Human Ventricles, Circ. 3 :95, 1957. 

19. Hecht, H. H. : Potential Variations of the Right Auricular 
and Ventricular Cavities in Man, Am. Heart J. 32 :39, 1946. 

20. Levine, H. D. ; Hellems, H. K. ; Dexter, L., and Tucker, 
A. S. : Studies in Intracardiac Electrography in Man. II. The 
Potential Variations in the Right Ventricle, Am. Heart J. 
37:64, 1949. 

21. Schlesinger, P. ; Benchimol, A. B., and Catrium, M. R. : 
Intracavity and Esophageal Potentials in Right Ventricular 
Hypertrophy, Am. Heart J. 37:110, 1949. 

22.. Emslie-Smith, D. : The Intracardiac Electrogram as an 
Aid in Cardiac Catheterization, Brit. Heart J. 17 :219, 1955. 


BENJE BOONS HAFT, M.D., St. LouU 


Autoimmune Disease and 
Thyroid Autoantibodies 


I. Autoimmunity 

There has been an increasing interest in the 
concept of autoimmune disease in recent years. 
A multitude of immunoglobulins have been iso- 
lated and identified in the serum of patients with 
a wide variety of diseases such as the antinuclear 
factor in systemic lupus erythematosus, the rheu- 
matoid factors in rheumatoid arthritis, the anti- 
thyroid antibodies in Hashimoto’s struma and 


This review presents evidence that some 
diseases of the thyroid gland are based on 
autoimmune mechanisms as their etiologic 
agent. 

This is one of a series of seminars pre- 
sented to the Medical House Staff, Jewish 
Hospital, St. Louis, edited by Michael M. 
Karl, M.D., Acting Director, Department of 
Medicine of the hospital. 

Dr. Boonshaft is presently in the United 
States Air Force. He was formerly an as- 
sistant resident in medicine at the Jewish 
Hospital, St. Louis. 


many others. There is an overlap in the clinical 
features of the connective tissue or collagen dis- 
eases as well as a similar overlap in the humoral 
autoantibodies of these diseases. 

Some investigators have postulated that some 
individuals have an unusual sensitivity of their 
immune apparatus to autoimmunization. The 
fact that these diseases may be familial also lends 
support to the concept that some basic immuno- 
logic difficulty may exist. It has also been shown 
that family members of a patient with autoim- 
mune disease may have various autoantibodies 
even though the individual is clinically well. 

The concept of autoimmunity and antibodies 
dates back only to 1900 with the first experiments 
of Ehrlich and Morgenroth who injected goats 
with red blood cells of other goats to form iso- 
antibodies to the injected red blood cells. Today, 
there are two concepts in regard to the type of 


antibodies formed; the humoral autoantibody 
and the delayed or cellular autoantibodv. There 
is experimental and clinical evidence that the 
humoral autoantibody can produce lesions only 
when the antigens are readily available, such as 
cells in suspensions (erythrocytes, leukocytes), 
vascular endothelium and certain vascular base- 
ment membranes. The humoral autoantibodies 
are unable to produce lesions in solid tissues 
such as thyroid, which suggests that the anti- 
body cannot react with the antigen containing 
cells in the circulation due to barriers either in 
the vessel wall or in the organized tissue. 

In the case of the delayed or cellular antibody, 
lesions may be produced in a variety of solid 
vascularized tissues that give rise to inflamma- 
tory and destructive lesions in the antigen-con- 
taining tissue. This is best shown by the success- 
ful passive transfer with living lymphoid cells as 
shown by experimental auto-allergic thyroiditis. 
The inflammatory reaction in the solid tissues 
has morphologic characteristics compatible with 
delayed hypersensitivity reactions. 

A. Criteria for Autoimmune Diseases— In 
1957, Witebsky and coworkers proposed four 
criteria to consider a disease an autoimmune dis- 
order: 

1. The direct demonstration of free, circulat- 
ing antibodies that are active at body tempera- 
ture or of cell-bound antibodies by indirect 
means. 

2. The recognition of the specific antigen 
against which this antibody is directed. 

3. The production of antibodies against the 
same antigen in experimental animals. 

4. The appearance of pathologic changes in 
the corresponding tissues of an actively sensi- 
tized experimental animal that are basically 
similar to those in human disease. 

A fifth criterion has been contemplated: The 
successful transfer of the disease by an antibody- 
containing serum or by immunologically stimu- 
lated lymphoid cells. 2 

B. Comparison of Two Categories of Auto-Im- 
mune Disease— The two basic ways in which 
autoantibodies can be evoked, namely by break- 


182 


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AUTOIMMUNE DISEASE— BOONSH AFT 


183 


down of immunologic tolerance or by release of 
secluded antigens, appear to underlie two broad 
categories of spontaneous antoimmune diseases. 
It is visualized that the effectors of an abnormal 
immune response, i.e., the sensitized lympho- 
cytes and the circulating antibodies, possibly act- 
ing in synergism with each other, are capable of 
giving rise to destructive inflammatory lesions in 
the tissues containing the relevant auto-antigens, 
and that when the conditions are suitable this 
can lead to a progressive disease which derives 
some of its momentum from the continued re- 


lease of further stimulating antigen from the 
affected tissue cells. 

In the “disturbed antigen” disease relevant 
organ constituents are considered inaccessible to 
the lympho-reticular system and so fail to estab- 
lish immunological tolerance in early life. In 
contrast, the antigens characteristically involved 
in SLE are widely distributed in the body com- 
ponents as is the case of the DNA protein and 
even present in the antibody forming cells them- 
selves; therefore, tolerance to them must be pre- 
sumed to exist in normal states. 


TABLE 1 

COMPARISON OF TWO CATEGORIES OF 
AUTO IMMUNE DISEASE 


“ Disturbed-Antigen ” “Disturbed-T olerance” 

Disease Disease 


Exemplified by Exemplified by SLE 

Lymphadenoid Goitre 


Differences 


Antigen not normally 
circulating. 

Immune tolerance to 
antigens probably not 
established. 

Organ-specific antibodies 
produced in patient. 
Antibodies have narrow 
species-specificity. 

Narrow spectrum of 
antibodies produced. 
Antigens capable of 
evoking antibody response 
in healthy animals. 
Experimental lesions 
resemble human disease. 
Relatives of patient have 
tendency to several thyroid 
diseases. 


Antigen accessible to 
lymphoid cells. 

Tolerance to antigens 
established in early life. 
Antibodies not necessarily 
organ-specific. 

Antibodies have wide 
species-specificity. 

Often a wide variety of 
antibodies in patient’s 
serum. 

No antibodies produced in 
animals with comparable 
stimulation. 

Human disease difficult to 
reproduce in animals. 
Relatives have disturbances 
of -globulin synthesis. 


Similarities 


Circulating auto-antibodies to normal body constituents. 
Tendency to raised level of serum -globulin. 

Lymphoid invasion of affected organs. 

Variable damage to cells containing auto-antigens. 
Greater incidence in women. 

Disease process not always progressive (cf. discoid LE 
and focal thyroiditis ) . 

Circulating antibodies not primarily responsible for tis- 
sue damage ( except presumably in haemolytic anaemia ) , 
but may act synergistically with “delayed type” hyper- 
sensitivity reactions. 


Reproduced from Hijimans, Doniach, Roitt and Holborow : 
1961, Brit. Med. J. ii, 909. 


II. Thyroid Autoantibodies 

A. History — When the animal body is con- 
fronted with foreign proteins or other materials, 
an immunological response is provoked in the 
lymphoid tissue leading to the production of 
specific circulating antibodies. In 1900, Ehrlich 
and Morgenroth 4 came up with the concepts of 
hetero-antibody, iso-antibody and autoantibody 
which referred to ( 1 ) antibodies formed by in- 
jection of substances from different species, 
“hetero-antibody” (2) antibodies produced by 
injection of substances from other members of 
the same species, “iso-antibody,” and (3) anti- 
bodies acting upon the constituents of an ani- 
mal’s own body, “autoantibody.” However, these 
investigators felt that the individual would not 
produce antibodies against his own tissues and 
formulated the principle called horror autotox- 
icus. However, this principle was to be later dis- 
proved by Rose and Witebsky. 

The next work was done by Uhlenhuth 5 in 
1903 when he demonstrated organ specific auto- 
antibodies in animal experiments using bovine 
lens as the antigen which was followed up with 
experiments showing similar organ specific anti- 
gens in brain tissue, spermatozoa and extracts of 
thyroid glands. In 1928, Witebsky and Steinfeld 
injected rabbits with bovine brain intravenously, 
which resulted in the appearance of organ spe- 
cific antibodies which reacted selectively with 
brain antigens. The first report of circulating 
antibodies in the serum of patients with thyroid 
disease was that of Papazolu 6 in 1911 who de- 
scribed a positive complement fixation reaction 
between the serum from hyperthyroid subjects 
and an extract of the thyrotoxic gland. In 1923, 
Hektoen 7 and his associates produced precipitat- 
ing antibodies to thyroid extracts in animals by 
injecting extracts of homologous and hetero- 
logous thyroid glands intravenously into rabbits, 
and organ specificity, but not species specificity, 
was demonstrated in that the antisera would 
react only with extracts of thyroid glands from 


184 


AUTOIMMUNE DISEASE— BOONS H AFT 


Missouri Medicine 
March, 15*64 


various species and not with extracts of other 
glands. Except for Lerman’s 8 work in 1942 when 
he found that immunization of rabbits with hu- 
man thyroglobulin led to the formation of anti- 
bodies not only against human thyroglobulin but 
also against rabbit thyroglobulin there was little 
further progress made until 1955. 

Witebsky, Rose and Shulman 9 in 1955 initi- 
ated the resurgence of interest in thyroid anti- 
bodies by immunizing rabbits with extracts of 
their own or other thyroid tissue added to 
Freund’s adjuvant (mineral oil and killed bac- 
teria) with the production of autoantibodies in 
the blood of the rabbits, as well as frequently 
producing histologic changes in the thyroid 
glands suggestive of changes seen in Hashimoto’s 
disease. The antibodies produced were subse- 
quently tested for by the precipitin, complement 
fixation and the tanned red cell hemagglutination 
technics, and these antibodies were shown to be 
organ specific and relatively species specific. By 
their work, Rose and Witebsky challenged a 
fundamental concept of immunology, namely, 
that an animal cannot produce an autoantibody 
against any of its own protein. 

At the same time, the finding of an abnormal 
elevation of gamma globulin and the subsequent 
abnormality of serum flocculation tests (CCF, 
TT) in patients with Hashimoto’s disease led 
Roitt, et al. 10 to suspect a long continued auto- 
immune reaction. They found that a precipitate 
developed when the serum from a patient with 
Hashimoto’s disease reacted with an extract of 
human thyroid gland and this suggested to them 
that the serum contained antibodies to a con- 
stituent of the human thyroid. 

B. Types of Thyroid Antibodies — The princi- 
pal autoantibodies known to be found in Hash- 
imoto’s disease and methods used to detect them 
are shown in Table 2. 11 

1. Thyroglobulin Antibody 

In 1957, the first report was made by Witeb- 
sky 12 who demonstrated that 12 of 18 patients 
were found to have circulating antibodies against 
human thyroid extract in people with the diag- 
nosis of chronic thyroiditis. It was later shown 
that serum of patients with Hashimoto’s disease, 
if mixed with crude or fine extracts of human 
thyroid gland, would give precipitin reaction. 
The precipitin titers were found to be the highest 
in the untreated patients; and the titers were 
lower in those treated with thyroid. These pre- 
cipitating antibodies to the thyroglobulin, which 
is the active antigen, can easily be detected by 


TABLE 2 

PRINCIPAL AUTOANTIBODIES IN HASHIMOTO’S 
DISEASE 


Autoantigen 

Tests for Autoantibody 

Thyroglobulin 

Precipitin 
Tanned-red cell 
agglutination 
Coons technic on fixed 
sections 

Passive cutaneous 
anaphylaxis 

Colloid component other 
than thyroglobulin 

Coons technic on fixed 
sections 

Intracellular microsomal 
antigen 

Complement fixation 
Coons technic on unfixed 
sections 

Cytotoxic effect of serum 
on tissue-culture thyroid 
cells 

Nuclear component 

Coons technic on 
unfixed section 


Ouchterlowy’s technic of agar-gel diffusion. Don- 
iach, Roitt and others 13, 14, 15 have extensively 
studied the precipitin system and fractionation 
of the Hashimoto serum by zone electrophoresis, 
followed by precipitin tests on the eluted frac- 
tions, showed that the antibody was located ex- 
clusively in the gamma globulins, and this was 
confirmed by immuno-electrophoresis in agar. 

An equally specific but much more sensitive 
method is the tanned-red-cell agglutination test 
whereby thyroglobulin is adsorbed on the sur- 
face of red cells that have been treated with 
dilute tannic acid and agglutination of these cells 
occurs in the presence of antibody to thyroglob- 
ulin. By this method antibody can be detected 
at a concentration 40,000 times less than that 
required for a positive precipitin reaction. These 
antibodies were not of the cold agglutinin type 
inasmuch as the hemagglutination reaction oc- 
curred at 37 C., as well as room temperature. 

Coon’s fluorescent antibody technic has been 
applied to the study of the antigen-antibody 
reaction in the thyroid gland. In the original 
method, an antibody solution of high titer is con- 
jugated with fluorescein isocyanate, and the re- 
sultant fluorescent-antibody solution is then em- 
ployed as a specific histo-chemical stain on tissue 
sections. Whenever antigen-antibody precipitates 
form, the fluorescent antibody is fixed, and exam- 
ination of the section under the fluorescent mi- 
croscope reveals a brilliant yellow-green color. 


Volume 61 
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AUTOIMMUNE DISEASE — BOONSHAFT 


185 


In the technic of passive cutaneous anaphy- 
laxis, intradermal injection of human thyroid ex- 
tract into Hashimoto’s patients produced erythe- 
ma and induration which was maximum at 24 
hours, and usually occurred in the patients with 
precipitins. 16 Another test of passive cutaneous 
anaphylaxis is shown by the intradermal injec- 
tions of serum at varying dilutions into the skin 
of a guinea pig, and later the animal is chal- 
lenged with an intravenous injection of the anti- 
gen ( thyroglobulin ) solution mixed with Evans- 
Blue Dye. 17 The diffusion of the blue dye into 
the skin indicates the reaction of thyroglobulin 
with antibody in the injected serum within a 
few minutes. It is not clear whether these cuta- 
neous reactions should be interpreted as Arthus’ 
phenomena or as manifestations of the “tuber- 
culin type” hypersensitivity, since a late appear- 
ance of maximum response is also observed in 
severe Arthus reactions. 

2. Colloid Component Other Than 
Thyroglobulin 

In some patients studied by White 18 using the 
gel-plate diffusion, it was found that certain 
Hashimoto sera gave two precipitation lines with 
the thyroglobulin, probably implying two mol- 
lecular species in the thyroglobulin which have 
certain antigenic determinants in common. The 
evidence obtained for the presence of a colloid 
autoantigen other than thyroglobulin is that in 
certain patients with Hashimoto’s disease with 
raised flocculation tests and high gamma glob- 
ulins, but with no thyroglobulin or complement- 
fixing microsomal antibodies, the colloid of thy- 
roid sections stained by the Coon’s technic gives 
a pattern distinct from that obtained with the 
thyroglobulin precipitins. The presence of in- 
complete antibodies to thyroglobulin was exclud- 
ed by co-precipitation studies with I 131 thyro- 
globulin, antigamma globulin serum, and tests 
for blocking antibody. 16 Anderson, et al. 19, 33 
have reported that nine of 53 patients with Hash- 
imoto’s thyroiditis had a complement-fixing anti- 
body directed against thyroglobulin by utilizing 
immunoelectrophoretic technics and differential 
absorption technics to separate the antibodies 
and showed thyroglobulin as the antigen. Other 
investigators have had trouble demonstrating this 
complement-fixing antibody to thyroglobulin. 

3. Intracellular Microsomal Antigen 

The first complement fixation ( CF ) reaction to 
thyroid extract was shown by Papazolu 6 in 1911 
when the sera of patients with thyrotoxicosis re- 


acted with extracts of thyrotoxic thyroid glands. 
Trotter, et al. 20 reported that most patients with 
Hashimoto’s disease have a distinct immune sys- 
tem in which the antibodies fix complement with 
extracts of thyrotoxic gland as well as in many 
cases of spontaneous myxedema, some cases of 
thyrotoxicosis, and occasionally in normal people. 
The complement fixing antibody is measured by 
superimposing a hemolytic reaction which also 
requires complement on the antigen-antibody 
reaction. If the patient’s serum contains comple- 
ment-fixing antibody, the secondary hemolytic 
reaction cannot occur, and in the absence of anti- 
body, the RBC is hemolyzed. This is the standard 
complement-fixation test. 

It has been shown that there are two distinct 
thyroid antigen-antibody systems involved in the 
precipitation and CF reactions as demonstrated 
by Roitt and Doniach. 13 This has been shown by 
the fact that absorption of precipitins from Hash- 
imoto’s serum with thyroglobulin has no effect on 
the serum titer in the CF test. It has also been 
shown that these two antigens are located at dif- 
ferent sites in the thyroid. The thyroglobulin is 
predominately intrafollicular, and the CF anti- 
gen is located intracellularly as shown by the 
ultracentrifugation with the CF antigen located 
in the “microsome fraction.” 13 The antigen has 
also been demonstrated in lower activity in the 
microsomal fraction of normal and nontoxic 
goiter. The CF thyroid antigen is organ specific 
and the antibody only cross-reacts with thyroid 
from closely related species (rhesus monkey, 
chimpanzee), but has no effect or cross-reaction 
with fiver, kidney or brain. 

It has been shown that some patients with thy- 
rotoxicosis have the antibody against CF antigen 
in high concentration with no thyroglobulin anti- 
body, and vice versa. The Coon’s fluorescent anti- 
body technic on unfixed sections showed that the 
fluorescein-conjugated Hashimoto serum reacted 
not only with normal thyroid gland, but also with 
patient’s own gland and gives specific staining 
in the colloid and in scattered thyroid globules 
within epithelial cells. It has been demonstrated 
that diffuse cytoplasmic staining corresponds 
with the presence of complement-fixing micro- 
somal antibody. The staining is inhibited by prior 
absorption of the sera with thyroid microsomes, 
but is unaffected by treatment with thyroglob- 
ulin. 

The CF antigen obtained from thyroid gland 
homogenates by differential centrifugation shows 
90 per cent of the CF activity in the subcellular 
fractions concentrated in the microsome portion 


186 


AUTOIMMUNE DISEASE— BOONSII AFT 


Missouri Mldicink 
March, 1964 


in contrast to the bulk of the thyroglobulin re- 
covered in the supernatant fraction. It appears 
that the antigenic potency of thyroid cells is re- 
lated more closely to the functional activity. This 
has been shown by Roitt and Doniach 1 '’ in a 
study of patients with hyperfunctioning adenoma 
in one lobe of the thyroid. The functional activ- 
ity of the normal lobe is suppressed since the 
overactive adenoma leads to inhibition of secre- 
tion of TSH by the pituitary. In these cases, CF 
activity of the adenomal was several times higher 
that that of the normal lobe. However, Anderson, 
et al. 19, 33 have found high CF activity in hyper- 
plastic thyroids of goitrous cretins with various 
forms dyshormonogenesis due to enzyme de- 
ficiencies; this implies that the antigen is not 
necessarily related to effective hormone produc- 
tion. 

4. Cytotoxic Antibody 

It has been shown by Pulvertaft, et al. 21 that 
sera from patients with Hashimoto’s disease have 
a cytotoxic effect on trypsinized human thyroid 
cells in tissue culture from patients’ own thyroid 
as well as those from thyrotoxic and nontoxic 
nodular goiter. The thyroid cells are set up in 
primary culture in presence of Hashimoto sera 
and they fail to grow; however, if the cells are 
cultured from 18 to 24 hours in normal serum 
and then placed in Hashimoto’s sera, the cells 
are killed. If the cells are grown for 36 hours 
in normal serum, then the thyroid cells are no 
longer affected by subsequent exposure to the 
cytotoxic serum, and it is thought that the thy- 
roid cells gradually acquired some protective 
coating. The cytotoxic effect is also abolished by 
heating the serum to 56 C. The cytotoxic con- 
stituent has been obtained from Hashimoto sera 
in which routine tests for thyroglobulin or for CF 
antibodies were negative, which suggests the 
cytotoxic factor distinct from these antibodies. 
Further evidence is that the thyroglobulin pre- 
cipitating antibody is heat stable, and the cyto- 
toxic antibody is heat labile. However, Hall 11 in 
his recent article stated that he had a personal 
communication from Doniach and Roitt, who 
have evidence that the microsomal CF antibody 
is identical with the cytotoxic antibody. How- 
ever, Chandler, et al. 41 recently showed that 
there was a lack of correlation between the CF 
antibody and the thyrocytotoxic antibody, sug- 
gesting that they are two distinct antibodies. 

The cytotoxic factor has been shown to be 
localized in the gamma globulin (7S size pro- 
teins). Although the thyroglobulin antibody and 


the cytotoxic occur together, high titer tanned 
red cell or positive precipitins may be present in 
sera that does not contain cytotoxic factor. How- 
ever, a close relationship has been shown by 
Forbes, et al. 25 who showed both the cytotoxic 
and microsomal CF antibody to be present in 85 
of 86 patients. The cytotoxic factor is found to 
be high in Hashimoto’s disease (47/50), thyro- 
toxicosis (25/35), myxedema and focal thyroid- 
itis. However, 8/91 (9 per cent) of patients with- 
out overt thyroid disease had cytotoxic antibod- 
ies as well as 34/118 (29 per cent) of close rela- 
tives of patients with thyroid disease had the 
cytotoxic antibody. It has been shown 26 that 
complement is needed for the activity of the 
cytotoxic factor. The importance of the cell sur- 
face interaction with the antibody is shown by 
the fact that the antibody combination is re- 
stricted to the cell surface until after the addition 
of complement when the binding of the sub- 
cellular elements of the cytoplasm can be ob- 
served after the rupture of the cell membrane. 
Also, although the cytotoxic antibody is found in 
thyrotoxic patients with mild and focal thyroid- 
itis, this suggests that the presence of the cyto- 
toxic antibody does not imply progressive tissue 
destruction. 

5. Nuclear Component 

White, 22 utilizing the Coon’s technic, has found 
the reaction localized to nuclei of the thyroid 
slice in four out of 25 patients, and later this 
serum factor was also shown to be fixed by the 
nuclei of other tissues, and this factor has been 
shown to be present in up to 10 per cent of pa- 
tients with Hashimoto’s disease. 

C. Experimental Autoimmune Thyroiditis— A 
circulating thyroid autoantibody was produced 
by immunizing a rabbit with thyroid extract plus 
Freund’s adjuvant, and this produced in from 
two to three months varying degrees of infiltra- 
tion with lymphoid cells and eosinophils around 
the thyroid follicles. Further studies revealed 
that the use of purified thyroglobulin produced 
serum antibodies and histologic changes in rab- 
bits similar to those seen following use of ex- 
tracts. It was also shown that the lesion present 
at four weeks in the rat thyroid as confirmed by 
hemithyroidectomy generally undergoes regres- 
sion if no further immunizing injections are 
given. 12 The correlation between the antibody 
levels and histologic changes in the thyroid 
glands is not always good, extensive damage oc- 
curring in some animals without detectable anti- 
bodies and no damage being seen in other ani- 


Volume 61 
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AUTOIMMUNE DISEASE— BOONSHAFT 


187 


mals having a high titer of circulating antibodies. 

Rose and Witebsky 27 demonstrated that the 
thyroid autoantibodies of rabbit, dog, guinea pig 
and human would cross-react with thyroid ex- 
tracts of other species as shown by the tanned 
red cell hemagglutination as well as the gel 
double diffusion precipitating tests. Therefore, 
the thyroid autoantibodies, although specific for 
the thyroid, would cross-react with thyroid ex- 
tracts of certain other species and suggested the 
presence of a spectrum of antibodies all specific 
for the thyroid extract which was presumably 
thyroglobulin. 

D. Factors Predisposing to Thyroid Autoim- 
munity— Why should antibodies or delayed hy- 
persensitivity develop to constituents of the thy- 
roid gland? The presence of antibodies directed 
against the body’s own tissue suggests that there 
is an alteration of the antigen, or that certain bar- 
riers between the antigens and the antibody 
forming tissues have been removed or that the 
immune mechanism is abnormal. As of now, no 
abnormality of thyroglobulin has been detected 
in Hashimoto’s disease. A more likely explanation 
is that the immune process is initiated by abnor- 
mal exposure of thyroid antigens. 

The theory is that the colloid escapes, which 
leads to plasma cell reaction which results in 
antibody formation. The anti gen- antibody pre- 
cipitation then occurs at or within the thyroidal 
follicles, which leads to additional epithelial 
damage with more leakage of colloid and the 
cycle continues. 

TABLE 3 

FACTORS INITIATING THE AUTOIMMUNE 
PROCESS 

1 ) 

a) Virus infection 

b ) Basement-membrane lesion 

c) Genetic defect 

d ) Thyrotoxicosis 

2) Abnormality of immune mechanism 


A. Viral infection of the thyroid causes dam- 
age to the thyroid cells and transient appearance 
of autoantibodies in low titer, but progressive 
lesions of the thyroid gland have not occurred. 
Also, it seems unlikely that a short period of 
thyroglobulin release as in viral thyroiditis could 
lead to a progressive autoimmune process since 
thyroglobulin is also released transiently after 
thyroidectomy and RAI, and yet a progressive 
autoimmune process does not develop. 


B. It has been shown that patients with chron- 
ic thyroiditis have changes in the basement mem- 
brane which consist of smudging, reticulation, 
vacuolization, loss of normal staining, thinning, 
reduplications and discontinuities. Stuart and 
Allan 28 have shown that seven of eight thyrotoxic 
patients with high antibody titers had extensive 
basement membrane damage which is focal and 
consists of fragmentation, bending and duplica- 
tion of the basement membrane with lympho- 
cytic and plasma cell infiltrates. In 10 patients 
with Hashimoto’s disease and high antibody 
titers, the changes in basement membrane were 
more diffuse and more severe. The reason for the 
leakage of colloid from the follicle is not under- 
stood, but the process may be analagous to the 
escape of protein through damaged glomerular 
basement membranes in nephritis. 

C. Hall, Owen, and Smart 29 have found evi- 
dence supporting a genetic predisposition to 
thyroid autoimmunity by studying families of 
patients with circulating antibodies. They stud- 
ied 24 propositi who all had some form of thy- 
roid disease and circulating antibodies, either 
tanned red cell hemagglutination and/or CF 
“microsomal” antibody. They found frequency of 
circulating antibodies among the sibs to be 54 
per cent, which is not significantly different from 
the expected 50 per cent for dominant heritance. 
It was found that positive serologic findings 
were more common among the females. Possibly 
the defect was in the gland itself, allowing con- 
tact between the immunity mechanism and sub- 
stances normally confined to the intracellular or 
intrafollicular sites; for example, the basement 
membrane. 

D. Patients with thyrotoxicosis seem to have 
predisposition to thyroid autoimmunity, since 
two-thirds of these patients have low titers of 
circulating antibodies. The relation between thy- 
rotoxicosis and thyroiditis must remain specula- 
tive, but a common genetic defect may be re- 
sponsible for both conditions. 

E. The incidence of thyroid antibodies has 
varied from series to series. Iiackett, et al. 30 re- 
ported an incidence of 18 per cent in 387 mixed 
medical patients without evidence of thyroid 
disorder, using the tanned red cell hemagglutina- 
tion technic. He also found antibodies in 9 per 
cent of 102 blood donors, and found positive re- 
sults in 42 of 69 (61 per cent) patients with thy- 
roid disease. Using the CF “microsomal” technic, 
he found an incidence of 6.8 per cent positive in 
sera of 486 hospital patients without clinical thy- 
roid disease. Hill 31 studied thyroglobulin anti- 


188 


AUTOIMMUNE DISEASE— BOONSH AFT 


Missoubi Medicine 
March, 1964 


body in 1,297 patients with normal thyroid in 
whose age-sex distribution was similar to those 
patients with myxedema and Hashimoto’s dis- 
ease, and found over 10 per cent of middle aged 
females have circulating antibodies. 

Doniach and Roitt 14 reported the finding of 
precipitins in 109 of 144 cases of Hashimoto’s 
disease, as well as in a few cases with spontane- 
ous, nongoitrous myxedema and with sub-acute 
thyroiditis. They also reported 13 an incidence of 
over 80 per cent antibodies in patients with non- 
goitrous hypothyroidism, as well as demonstrat- 
ing antibodies in patients with thyrotoxicosis, 
simple goiter and carcinoma. 13, 32 There have 
been numerous surveys in the literature utilizing 
the various antibody technics in the last six 
years. 10, 12 - 14 - 16 > 19 ’ 20 > 23 - 34 > 35 Roitt and Doniach 
in 1958 13 reported extensive studies on several 
hundred cases with various thyroid disorders, 
utilizing the precipitin, complement fixation and 
hemagglutination technics. Thyroid autoanti- 
bodies were demonstrated by one or more tech- 
nics in 98 per cent of 106 patients with Hashi- 
moto’s disease, 83 per cent of 101 patients with 
spontaneous adult myxedema, 64 per cent of 181 
cases of thyrotoxicosis, 33 per cent of 198 cases 
of nontoxic colloid goiter, 68 per cent of 19 pa- 
tients with subacute thyroiditis, and 29 per cent 
of 39 cases of thyroid cancer. The highest anti- 
body titers were found in Hashimoto’s disease 
and myxedema; in general, low titers were found 
in the other thyroid diseases, and the presence of 
autoantibodies was associated with localized 
lymphoid infiltration of the gland. Balfour, et al. 35 
reported that of 300 patients with Hashimoto’s 
disease, antibody studies utilizing the precipitin, 
tanned red cell agglutination, and CF micro- 
somal technics were positive in 95 per cent of 
the cases, and in two thirds of the cases, all three 
tests were positive. It was also shown that there 
was a secondary antibody to the colloid using 
fluorescent studies which was present as com- 
mon in the Hashimoto’s patients as was the thy- 
roglobulin and microsomal CF antibody. 

F. The coexistence of Hashimoto’s disease and 


other diseases of assumed autoimmune etiology 
has often been seen. Hashimoto’s disease has 
been seen in patients with Addison’s disease, 
Sjogren’s syndrome, progressive hepatitis, neph- 
rosis, acquired hemolytic anemia and collagen 
diseases. Hijmans, et al. 36 has done extensive 
work to show the relationship between SLE, 
rheumatoid arthritis and thyroid autoimmune 
disease. 

SLE, rheumatoid arthritis and thyroid disease 
have been shown to have a degree of overlap of 
autoantibodies greater than might be expected 
by chance. Patients with SLE have an incidence 
of thyroid antibodies three times greater than 
the normal antibodies. 

Skanse and Nilson 37 studied thyroid antibodies 
in patients with hypergammaglobulinemia, and 
showed tanned red cell agglutination tests were 
positive in from 2.7 to 17.6 per cent of patients 
without thyroid disease, and CF antibodies were 
positive in 2.9 per cent of patients. The thyroid 
antibody reactions were expected to be increased 
in patients with increased gamma globulins since 
in patients with Hashimoto’s disease the serum 
anti-thyroglobulin was found to be mainly lo- 
cated in the 7S and 19S gamma globulin. 40 


Disease 

TRC Per Cent 

CF Per Cent 

Disseminated Lupus . 

4/27 

ZZ 

14.8 

4/19 

= 

21 

“Diffuse Collagen” Dis. 

4/17 

= 

23.5 

1/12 

= 

8.3 

Cirrhosis 

1/30 

= 

3 

1/25 

= 

4 

Multiple Myeloma 

4/28 

= 

14.3 

2/28 

= 

7.2 

Macroglobulinemia 

3/23 

= 

13 

1/23 

= 

4.3 

Healthy 

10/250 

= 

4 

1/250 

ZZ 

.4 


The over-all incidence of positive TRC agglu- 
tination tests in hypergammaglobulinemia was 
13.5 per cent and that with CF antibodies was 
7.8 per cent, which was significantly higher than 
the controls. The outstanding feature of the 
study was the low incidence of positive tests in 
patients with cirrhosis of the liver. 

Pettit, et al. 38 studied 58 diabetics less than 16 


ANF (Anti- 

Clinical Dx No.ofPts. Thyroid (3 Tests) LE Cells nuclear) RA Latex 


SLE 60 15/60 = 25% 59/60 = 98% 59/60 = 98% 20/50 = 40% 

SLE and Hashimoto’s 5 5/5 = 100% 5/5 5/5 0/5 

Rheum. Arthr 79 9/79 = 11% 16/79 = 20% 40/79 = 50% 35/64 = 55% 

R.A. and Hashimoto’s 7 7/7 = 100% 0/7 3/7 5/7 

Hashimoto’s Uncomplicated 182 182/182 = 100% 0/110 14/182 = 8% 2/98 = 2% 

Controls 0 10% 0% 


Volume 61 
Number 3 


AUTOIMMUNE DISEASE— BOONSH AFT 


189 


years old and found 13/51 (22 per cent) had 
positive reactions and 10 other questionable 
( doubtful positive ) reactions for antithyroid an- 
tibodies using the Coon’s labeled antibody meth- 
od which demonstrates both agglutinating and 
CF antibodies. The explanation is that a bio- 
chemical dysfunction of the thyroid gland lead- 
ing to autoimmunization is an inherent com- 
ponent of hereditary diabetes mellitus, but is far 
overshadowed clinically by the dysfunction of 
the pancreatic islets. 

Chandler, et al. 41 have shown that there is a 
significantly greater incidence of a thyroid auto- 
immune process in mothers of athyreotic cretins 
(24.8 per cent) than in mothers of normal off- 
spring (6 per cent). Although this greater inci- 
dence is noted, analysis of the data did not sup- 
port the thesis that the antibodies were destruc- 
tive, but rather that these antibodies reflected an 
autoimmune process and that some unknown 
factor is responsible, such as possible role of de- 
layed hypersensitivity. 

Conclusions 

G. The underlying abnormality leading to the 
development of the autoimmune process is un- 
known. Autoimmunity can arise and lead to dis- 
ease when mechanisms of self-recognition fail or 
when organ-specific antigens are abnormally re- 
leased. Much remains to be learned about the 
factors which initiate tissue destruction and the 
role of genetic predisposition, in many instances 
of which, such as in rheumatoid arthritis, we still 
do not know much about the nature of the pre- 
sumed autoantigens involved in the disease. Re- 
cent work suggests the thymus is the key organ 
for development of normal immunologic respons- 
es and it is likely our understanding of auto- 
immune disease will greatly improve with fur- 
ther study of this difficult organ. 

Bibliography 

1. Harvey : Auto-Immune Disease and the Chronic Biologic 
False-Positive Test for Syphilis, J.A.M.A. 182 :513, 1962. 

2. Milgrom and Witebsky: Auto-Antibodies and Auto-Immune 
Disease. J.A.M.A. 181:706, 1962. 

3. Hijams, Doniach, and Roitt, Holborow: Serological Overlap 
Retween SLE. Rheumatoid Arthritis, and Thyroid Auto-Immune 
Disease, Brit. M. J. 2 :909, 1961. 


4. Ehrlich and Morgenroth : Ueber Haemolysine. Dritte Mit- 
theilung, Ber. Klin. Wehnschr. 21:453, 1900. 

5. Witebsky, et al. : Studies on organ specificity. I. The Sero- 
logical Specificity of Thyroid Extracts, J. Immunol. 75 :269, 
1955. 

6. Papazolu, A. : Contributions a l’Etude de la Patholgenie de 
la Maladie de Basedow, Compt. rend. Soc. de biol. 71:671, 1911. 

7. Hektoen and Schulhof : The Precipitin Reaction of Thyro- 
globulin, J.A.M.A. 80:386, 1923. 

8. Lerman : Endocrine Action of Thyroglobulin Antibodies, 
Endocrinol. 31:558, 1942. 

9. Rose and Witebsky: Studies on Organ Specificity, J. 

Immunol. 76:408, 417, 1956. 

10. Roitt, et al. : Auto-Antibodies in Hashimoto’s Disease, 
Lancet 2 :820, 1956. 

11. Hall: Immunologic Aspects of Thyroid Function, N. E. J. 
Med. 2 6 6:1204, 1962. 

12. Witebsky, et al. : Chronic Thyroiditis and Auto-Immuniza- 
tion, J.A.M.A. 164:1439, 1957. 

13. Roitt and Doniach: Human Auto-Immune Thyroiditis: 

Serological Studies, Lancet 2 :1027, 1958. 

14. Doniach and Roitt : Auto-Immunity in Hashimoto’s Disease 
and Its Implications, J. Clin. End. & Metab. 17 :1293, 1957. 

15. Roitt, et al. : The Nature of Thyroid Auto-Antibodies Pres- 
ent in Patients With Hashimoto’s Thyroiditis, Bioch. J. 69 :248, 
1958. 

16. Roitt, Doniach : Thyroid Auto-Immunity, Brit. Med. Bull. 
16:152, 1960. 

17. Ovary, et al. : Thyroid Specific Autoantibodies Studied by 
Passive Cutaneous Anaphylaxis of Guinea Pig, Proc. Soc. Exper. 
& Med. 99:397, 1958. 

18. White: An Immunological Investigation of Hashimoto’s 
Disease, Proc. Roy. Soc. Med. 50:953, 1957. 

19. Anderson, Goudie and Gray : The “Thyrotoxic” Complement 
Fixation Reaction, Soct. Med. J. 4 :64, 1959. 

20. Trotter, et al. : Precipitating and Complement-Fixing Anti- 
bodies in Hashimoto’s Disease, Proc. Roy. Soc. Med. 50:961, 
1957. 

21. Pulvertaft, et al. : Cytotoxic Effects on Hashimoto Serum 
or Human Thyroid Cells in Tissue Culture, Lancet 2 :214, 1959. 

22. White : Localisation of Auto- Antigens in Thyroid Gland by 
Fluorescent Antibody Technique, Exp. Cell Research 7 :263, 1959. 

23. Doniach, Roitt : Auto-Immunity in Hashimoto’s Disease and 
Its Implications, J. Clin. Endo. Metab. 17 :1293, 1957. 

24. Owne, et al. : A Review of “Auto-Immunization” in Hash- 
imoto’s Disease, J. Clin. Endo. and Metab. 18 :105, 1958. 

25. Forbes, et al. : The Thyroid Cytotoxic Antibody, J. C. I. 
41 :996, 1962. 

26. Pulvertaft, et al. : The Cytotoxic Factor in Hashimoto’s 
Disease and Its Incidence in Other Diseases, Brit. J. Exper. 
Path. 42 :496, 1961. 

27. Rose and Witebsky: Cross-Reactions of Thyroid Antibody 
With Thyroid of Other Species, J. Immunol. 83 :35, 1959. 

28. Stuart, Allan : Significance of Basement-Membrane Changes 
in Thyroid Disease, Lancet 2 :1204, 1958. 

29. Hall, et al. : Evidence for Genetic Predisposition to the 
Formation of Thyroid Auto- Antibody, Lancet 2 :187, 1960. 

30. Hackett, et al. : Thyroglobulin Antibody in Patients With- 
out Clinical Disease of the Thyroid Gland, Lancet 2 :402, 1960. 

31. Hill: Thyroglobulin Antibodies in 1297 Patients Without 
Thyroid Disease, Brit. M. J. 1 :793, 1961. 

32. Stuart and Allan : Auto- Antibodies in Thyroid Carcinoma, 
Lancet 2 :47, 1958. 

33. Anderson, et al. : Thyroglobulin Complement Antibody in 
Hashimoto’s Disease, Lancet 1 :644, 1959. 

34. Blizzard, et al. : Thyroglobulin Antibodies in Multiple Thy- 
roid Diseases, N. Eng. J. Med. 260:112, 1959. 

35. Balfour, et al. : Fluorescent Antibody Studies in Human 
Thyroiditis, Brit. J. Exper. Path. 42 :307, 1961. 

36. Hijams, et al. : Serological Overlap Between SLE, Rheuma- 
toid Arthritis, and Thyroid Auto-Immune Disease, Brit. M. J. 
2:909, 1961. 

37. Skanse, Nilsson: Thyroid Antibodies in Hypergammaglo- 
bulinemia, Acta Medica Scand. 170:599, 1961. 

38. Petit, et al. : Antithyroid Antibodies in Juvenile Diabetics, 
J. Clin. Endo. & Metab. 21:209, 1961. 

39. Blizzard and Chandler: The History and Present Concepts 
of Autoimmunization in Thyroid Disease, J. Ped. 5 7 :399, 1960. 

40. Shulman, et al. : The Antibody Molecule in Electrophoretic 
Patterns in Chronic Thyroiditis, J. Lab. Clin. Med. 55 :733, 
1960. 

41. Chandler, et al. : Incidence of Thyrocytotoxic Factor and 
Other Antithyroid Antibodies in the Mothers of Cretins, New 
Eng. J. M. 267:376, 1962. 


EUGENE T. DMYTRYK, M.D., St. Louis 


Intestinal Obstruction Following Anastomosis 
With the Rankin Clamp 


Intestinal obstruction is one of the more com- 
mon emergencies of abdominal surgery and con- 
sistently challenges the abdominal surgeon. There 
are many causes of intestinal obstruction as clas- 
sified by Zuidema 1 * * * 5 * in the textbook “Surgery” by 
Nardi and Zuidema published in 1961. Other 
classifications of intestinal obstruction have been 
reviewed 2-6 but this clinical classification is prob- 
ably the most complete one available. 

Among the causes of postoperative obstruc- 
tions, stomal obstruction due to edema and stric- 
ture are noted. This particular type of obstruc- 
tion— stomal— is the basis for this presentation of 
three cases seen between September 1958 and 
March 1961. 

The late Dr. Fred W. Rankin first presented 
his method for an aseptic intestinal anastomosis 
utilizing the instrument which bears his name in 
1928. 7, 8 Many of the younger practicing sur- 
geons and the majority of surgical house officers 
today are not familiar with the Rankin clamp 
and the technic of using it properly. This is 
understandable since the Rankin clamp was de- 
vised in the pre-antibiotic era when colon sur- 
gery carried a “prohibitive” mortality, especially 
when compared to current day statistical data. 
They would do well to review this excellent 
treatise of original clinical investigation. 

The detailed technic for proper use of the 
Rankin clamp is described elsewhere 7 ’ 8 and 
will not be repeated here. The last line of the 
paragraph which describes the clamp and its use 
bears repetition— “The diaphragm must be bro- 
ken out with the fingers through the lumen.” 

These three cases are presented as a clinical 
review because they all had one common de- 
nominator— a postoperative obstruction following 
anastomosis with the Rankin clamp. The primary 
pathology was different in all three patients and 
all had difficult and complicated postoperative 
courses. 

Case Reports 

Case 1. A 24-year-old male was admitted to the 
hospital on September 13, 1958, with constant and 
severe right lower quadrant pain of 18 hours dura- 


tion associated with nausea. There had been no 
vomiting or changes in bowel habits. Pertinent find- 
ings on physical examination were limited to the 
abdomen where right lower quadrant tenderness was 
noted with a palpable, tender, mobile mass measur- 
ing 5 by 3 cms. The temperature was 99 F., hemo- 
globin and hematocrit were normal and white cell 
count was 8,900 with a normal differential count. 


Three case reports are presented in which 
obstruction following anastomosis utilizing 
the Rankin clamp are presented. 

Dr. Dmytryk is from the Department of 
Surgery, St. John’s Hospital, St. Louis. 


He was taken to the operating room shortly after ad- 

mission with a preoperative diagnosis of acute ap- 
pendicitis, questionable regional ileitis. At operation 

the distal ileum for approximately 12 inches was red 
and thickened; no skip areas were noted. The ce- 
cum and appendix were normal. The abdomen was 
closed without removing any tissue. His immediate 
postoperative course was uneventful and he was dis- 
charged on his seventh postoperative day. 

This patient was readmitted to the hospital on 
February 9, 1959, because of cramping abdominal 
pain of one month duration. For two days prior to 
admission nausea and vomiting prevailed, but there 
was no diarrhea or rectal bleeding. Physical findings 
of significance were limited to the abdomen. A 5 by 

5 inch tender, non-movable mass was palpated in 

the right lower quadrant. Hyperactive bowel sounds, 

associated with cramping pain, were heard over the 
entire abdomen. The patient was moderately de- 
hydrated. Routine blood counts were reported to be 
within limits of normality. 

After hydration and decompression the patient 
was operated upon on February 12, 1959. The ter- 
minal ileum and cecum were thickened and adherent 
to the lateral aspect of the abdominal wall in the 
right iliac fossa. A right hemi-colectomy was per- 
formed restoring the intestinal continuity with an 
end to end ileo-transverse colostomy utilizing a Ran- 
kin clamp. A “skip” area in the upper jejunum was 
also excised and intestinal continuity restored with 
an end to end Rankin clamp anastomosis. The patho- 

190 


Volume 61 
Number 3 


INTESTINAL OBSTRUCTION— DMYTRYK 


191 


logic report on the tissue was: Cicatrizing enteritis 
(regional ileitis). 

The postoperative course was as follows: Febru- 
ary 14, 1959 (second postoperative day), Levine 
tube removed in the morning with vomiting occur- 
ring that evening; February 15, vomiting continued; 
abdomen distended; hypoactive bowel sounds; Feb- 
ruary 17, Wangensteen suction; marked abdominal 
distention; afebrile; February 19, vomited around 
Levine tube; abdomen distended; bowel sounds were 
present; tender in both lower quadrants; February 
20, spontaneous bowel movement; nauseated; vomit- 
ed one time; February 22, vomited 1,400 cc.; nause- 
ated; active bowel sounds; February 23, continuous 
drainage from the Levine tube; hypochloremia 70 
meq./L.; C0 2 43 meq./L.; Na. 139 meq./L; K. 3.4 
meq./L. 

On February 24 (twelfth postoperative day), the 
patient was taken to the operating room with a pre- 
operative diagnosis of intestinal obstruction. His old 
right rectus incision was reopened. The ileo-trans- 
verse colostomy was intact, but the proximal jejunum 
above the site of anastomosis was markedly distend- 
ed. It was at this point that I was called in con- 
sultation. The jejunum was completely obstructed by 
a diaphragm of tissue at the anastomosis site. A 
double jejunostomy was performed just distal to the 
obstruction. The obstructing diaphragm of tissue 
was broken via the proximal jejunostomy opening 
and then a catheter was passed proximal to the 
anastomotic site for decompression. 

The distal jejunostomy was used for “feeding” 
purposes. The intestinal contents from the proximal 
decompression tube were instilled into the distal 
tube by connecting the two tubes on March 1, 1959. 
His postoperative course from this time was un- 
eventful except for a wound infection. The jejunos- 
tomy tubes were removed on March 10, and he left 
the hospital on March 14, 1959. 

Case 2. This 55-year-old female was hospitalized 
on January 20, 1960, because of abdominal pain of 
three days duration and anorexia. The pain was peri- 
umbilical at onset and gradually localized in the 
right lower quadrant. Examination revealed a pal- 
pable tender mass in the right lower quadrant with 
muscle guard, rebound tenderness and hypoactive 
bowel sounds. No temperature elevation was present 
and the white cell count was 11,600 with a normal 
differential count. 

Two hours after admission the patient was taken 
to the operating room with a preoperative diagnosis 
of acute appendicitis with abscess. A mass was found 
in the ascending colon and was removed by a right 
hemi-colectomy. The intestinal continuity was re- 
stored with a side to side anastomosis using the 
Rankin clamp. 

Pathologic report was diverticulum of cecum with 
perforation and abscess formation; mucosal polyps 
of cecum. 

The postoperative course was as follows: January 
22 (second postoperative day), abdomen was soft 


with no distention; bowel sounds were present, Le- 
vine tube was removed; January 23, moderate ab- 
dominal distention; high pitched bowel sounds; Le- 
vine tube inserted; January 24, abdomen soft with 
no distention; bowel sounds present; afebrile; Jan- 
uary 25 seen in consultation. The abdomen was dis- 
tended with a tympanitic percussion note. Bowel 
sounds were active but gave the impression of an 
obstruction, that is losing its bowel tone and de- 
clining to an ileus. X-rays of the abdomen revealed 
dilated loops of small bowel with fluid levels. 

The patient was taken to the operating room 
with a preoperative diagnosis of intestinal obstruc- 
tion. The peritoneal cavity was filled with straw 
colored fluid and the small intestine was dilated to 
three times its normal size with gas and fluid. The 
point of obstruction was the anastomotic site at the 
ileo-transverse colostomy. The anterior suture line 
had perforated and was sealed off by adherent 
omentum. The obstruction was due to a complete 
diaphragm of tissue at the site of anastomosis. A 
fairly wide resection of the ileum and colon was 
carried out and the intestinal continuity restored by 
an open end to end anastomosis. A catheter was 
placed in the ileum and passed beyond the anasto- 
mosis for decompression. 

The postoperative course was complicated some- 
what by electrolyte imbalances which responded 
readily to replacement therapy. On January 31 (fifth 
postoperative day), the patient had a spontaneous 
bowel movement and the Levine tube was removed. 
On February 1, 1960, the ileostomy catheter was re- 
moved and the fecal fistula closed spontaneously 
within one week. The patient was discharged on 
February 13, 1960. 

Case 3. This 59-year-old female was admitted to 
the hospital on March 30, 1961, with known cho- 
lelithiasis of 20 to 25 years duration. One week prior 
to admission she had a severe biliary colic. The 
admission laboratory work was all within limits of 
normality. Cholecystograms on April 1, 1961, re- 
vealed a poorly functioning gallbladder with mul- 
tiple calculi. On April 4, 1961, she was operated 
upon by the admitting physician and surgeon. An 
elective cholecystectomy, appendectomy and biopsy 
of an enlarged mesenteric lymph node were per- 
formed. The pathologist reported chronic cholecystitis 
with cholelithiasis and metastatic mucinus adenocar- 
cinoma of the mesenteric lymph node. 

At this point another surgeon was called in con- 
sultation. X-ray studies revealed a carcinoma of the 
sigmoid colon. On April 13, 1961, the patient had 
a sigmoidectomy performed with an end to end 
anastomosis performed with a Rankin clamp. Her 
postoperative course was unsatisfactory with abdom- 
inal pain, distention, leukocytosis and anemia. 

She was seen in consultation by me on April 19, 
1961 (sixth postoperative day), because of progres- 
sive abdominal distention and x-ray evidence of ob- 
struction with a dilated cecum measuring 13 cms., 
in diameter. An emergency cecostomy was performed 


192 


1NTES T1NAL OBS TRUCTION — DMYTRYK 


Missouri Medicine 
March, 1964 


under local anesthesia. The patient was transfused 
several times to correct her anemia and her electro- 
lyte balance was maintained with replacement ther- 
apy. A barium enema was done on April 24 (five 
days after cecostomy) and revealed a complete block 
at the operative site. On April 27, a wide left colec- 
tomy was performed and intestinal continuity re- 
stored with an open end to end anastomosis. The 
surgical specimen revealed a diaphragm and marked 
inflammatory changes at the site of anastomosis. The 
patient had a satisfactory postoperative course and 
was discharged on May 14, 1961. At the time of this 
report (two years later) she is alive and in good 
health. 

Summary 

Three unusual and interesting cases have been 
presented. They represent patients who were 
operated upon for three entirely different basic 
pathologic entities and subsequently developed 
obstruction following anastomosis utilizing the 
Rankin clamp. 

There is little doubt that in the pre-antibiotic 
era the Rankin clamp served a most useful pur- 
pose. However, it is my feeling that there is little 
or no need for its use today. I do feel that it 
would be a stimulating experience for those un- 
familiar with the Rankin clamp to review this ex- 
cellent treatise of original clinical investigation. 

University Club Bldg. 

Bibliography 

1. Nardi and Zuidema : Surgery — A Concise Guide to Clinical 
Practice, Boston, Mass., Little, Brown and Company, 1961. 

2. Babcock : Principles and Practice of Surgery, Philadelphia, 
Pa., Lea and Febiger, 1954. 

3. Mosley : Textbook of Surgery, Saint Louis, Mo., C. V. Mos- 
by Company, 1955. 

4. Shackelford : Surgery of the Alimentary Tract, Philadelphia- 
London, W. B. Saunders Company, 1955. 

5. Christopher : Textbook of Surgery, Philadelphia-London, 

W. B. Saunders Company, 1943. 

6. Maingot : Abdominal Operations, New York and London, 
D. Appleton-Century Company, Publisher, 1940. 

7. Rankin, Fred W. : An Aseptic Method of Intestinal Anasto- 
mosis, Surg., Gynec. & Obst. 47 :78-88, 1928. 

8. Rankin and Graham : Cancer of the Colon and Rectum, 
Springfield, Illinois, Charles C Thomas, Publisher, 1950. 


UNCERTIFIED CORRECTIONAL BIRTH 
RECORDS DISCONTINUED 

Physicians and hospitals have raised questions, 
according to the Division of Health, concerning 
its discontinuance of a procedure by which un- 
certified facsimile copies of birth records were 
mailed to the mothers for correctional purposes. 
The procedure has been discontinued by the Di- 
vision of Health because of the confusion which 
it caused and because of its exorbitant cost. 

For many years, the Division of Health has 
made a practice of mailing uncertified facsimile 
copies of babies’ birth records to the baby’s 
mother shortly after the time of birth. These fac- 
simile copies were sent out in order that the 
mother might have an opportunity 7 to correct 
any errors prior to the time that the certificate 
was made a permanent matter of record. The 
response on the part of mothers has decreased. 

In spite of the explanation which accompanied 
each uncertified copy, the mothers in many cases 
continued to feel that these were certified copies 
of birth and attempted to use them for official 
purposes. Such attempts resulted in inconve- 
nience and confusion. The program of sending 
uncertified copies to mothers was discontinued 
July 15, 1963. 

Parents may obtain a legal certified copy of 
their child’s birth record by submitting a request 
to the section of Vital Records, Division of 
Health, Jefferson City, Mo. When such a request 
is made, the mother should give the child’s name, 
the date and place of birth and the parents’ 
names. Upon receipt of this information and a 
fee of $1.00 as is required by law, the Division 
of Health will issue to the parents a certified 
copy of birth which has legal validity. 


MISSOURI STATE MEDICAL ASSOCIATION 
1 06th Annual Session 
Hotel Chase-Park Plaza, St. Louis 
March 8, 9, 10,11, 1964 


ADVERTISEMENTS 


193 






Young Woman 
Reading a Letter 

JOHANNES VERMEER 

1632-1675 



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Average Adult Dosage: One rounded tea- 
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CHICAGO, ILLINOIS, 60680 

Research in the Service of Medicine 



MARGARET C. L. GILDEA, M.D., St. Louis 


Some Thoughts on the New Community 
Mental Health Centers Program 


It is now almost 20 years since Congress passed 
the National Mental Health Act. One manifest 
result has been the great increase in interest in 
mental health services for everyone, in all settings, 
that has developed around the country. A great 
deal of this impetus was initiated and the momen- 
tum kept up by the Public Health Service, under 
whose auspices the National Health Institutes 
and especially the National Institute for Mental 
Health have developed. These have given strong 
leadership, continuing propulsion and direction 
to the entire movement. From 1947 on, funds 


The advantages of the mental health 
centers is discussed as well as the possibili- 
ties of set-up of the centers. 

Dr. Gildea is on the faculty of Wash- 
ington University School of Medicine. 


have been available to help in community plan- 
ning and services through the National Institute 
of Mental Health. This is now at a point in the 
development of federal interest and appropria- 
tions that the President has recommended, and 
Congress has approved, considerably larger sums 
of money to be spent by the individual states in 
community mental health operations, with spe- 
cial renewed emphasis on the development of 
local mental health centers. At this time (Octo- 
ber 24, 1963) a bill approving $150,000,000 for 
the construction of Mental Health Centers has 
passed both houses and awaits the President’s 
signature. A provision for the initial staffing of 
these centers has been deleted. Thus it remains 
the responsibility of the states to organize and 
staff these centers. 

The exact functions of these centers, and in 
fact the whole idea of community mental health, 
is broadly interpreted, and a wide range of ac- 
tivities can be subsumed under this heading. 
Every state differs in regard to health services 
available at present, depending on distribution 
of population, transportation facilities, the cul- 
tural and sociological character of the population 


and all the other factors that influence the ability 
of a population to support and to make use of 
community mental health services. For instance, 
the best possible clinic located in a city in one 
of the midwestern or western states is not able 
to offer much useful service to a population that 
lives farther away than an hour’s travel. 

When I first came to St. Louis I was impressed 
with the fact that many of the patients I saw at 
the Washington University Clinics, as well as 
in private practice, came from two to five hun- 
dred miles away. I have had patients commuting 
in for weekly treatment hours from five hundred 
miles away by air, but this is an extraordinarily 
impractical and uneconomical way to give men- 
tal health services because the machinery in- 
volved in making the trip may easily outweigh 
any possible benefits. Perhaps if a patient travels 
500 miles to see the doctor, the doctor has to do 
something 100 times better for the patient than 
if the patient has traveled only five miles. Think 
what a strain this puts on both doctor and pa- 
tient! The Public Health Service has long recog- 
nized this and has established neighborhood clin- 
ics for the care and immunization of children, 
and local health departments which offer a va- 
riety of other kinds of health services locally, on 
the spot. 

It is manifestly impossible to set up clinics 
organized on the lines laid down by professional 
standard setting organizations in so many com- 
munities throughout the country that no one 
would have to travel for more than an hour to 
attend. The expense would be prohibitive, and 
securing this number of people with the proper 
qualifications to staff and run these clinics would 
be out of the question at any time in the near 
future. The National Institute for Mental Health 
and other mental health promoting agencies 
have recognized this for years, and have pro- 
moted many conferences on the best utilization 
of local resources for mental health services in 
the communities where they already exist. I 
attended conferences 10 years ago in Florida 
and in Texas in order to discuss the best pos- 
sible ways to set up services locally, using the 


Volume 61 
Number 3 


COMMUNITY HEALTH CENTERS— GILDE A 


195 


material at hand, so that people could find the 
help they needed at home, or a reasonable dis- 
tance from where they lived. 

Of course the entire concept of bringing men- 
tal health services to local communities is not 
new. The concept of the traveling clinic was 
developed to solve this problem, and I remember 
20 years or so ago in Connecticut when traveling 
clinics were considered the ultimate in commu- 
nity services. Connecticut of course is quite a 
different kettle of fish from Missouri because in 
Connecticut practically nobody fives more than 
a half hour away from anywhere and a traveling 
clinic can get where it is going and back with 
much greater economy than in Missouri. 

During a recent session of the state legislature 
traveling clinics were established in all our state 
hospital districts, and there are 14 of these in 
operation in the state at present. I am sure they 
do a great deal of good for many patients, but 
the type of service which they can offer must be 
largely diagnostic or consultative. Certainly lit- 
tle actual treatment can be offered through this 
medium. Further than this the expense of these 
traveling clinics is great. Recent studies in Mis- 
souri show that each patient contact costs more 
than $40. In a clinic established in most communi- 
ties a patient contact costs between $10 and $25, 
and a recent study 1 shows that mental health 
visits by visiting nurses cost less than $6 each. 

It seems to me, then, essential that a com- 
pletely flexible approach should be maintained, 
and what each area has to offer in the way of 
services already available be considered. Many 
of these services can be expanded, developed 
and correlated to serve mental health purposes. 
This requires close cooperation centrally be- 
tween the organizations which control the local 
branches, and locally with the individual organi- 
zations. It goes without saying that it also re- 
quires close supervision and assistance to be of- 
fered to the workers at the local level in order 
to derive the most from the potential of these 
resources which are already there. 

There are at least five potential mental health 
resources covering the state. They are: 

1. To every citizen some kind of medical help 
is available from local doctors. It may not be 
close at hand, and it may not be within the fi- 
nancial reach of everyone, but medical help can 
be found for everyone, on some level. Although 
the local doctors are greatly pressured, and not 
always too well rewarded, they are continually 
offering their patients mental health assistance, 
whether they call it that or not. Much of this 
sympathetic and supportive help may reach the 


patient through the medium of the hypodermic 
needle (which is quicker than the psychiatric 
interview, and some people think just as effi- 
cient). These doctors could do much more in 
mental health services if their hands were 
strengthened by ancillary personnel with train- 
ing in mental health skills, and with an organ- 
ized community mental health center through 
which to work. I think, for instance, they would 
be especially helped by having the possibility of 
home visits occasionally by public health nurses. 

2. The state is covered by the Division of Pub- 
lic Health and its branches. Every county does 
not have its own health department but there 
are regional offices everywhere and the services 
of the public health staffs, including nurses, are 
available to everyone in the state. Public health 
nurses are playing an increasingly important 
role in the mental health field. 2 * 3 

3. The Department of Welfare also blankets 
the state. There are county welfare offices every- 
where and welfare workers are available to call 
on every home in the state. 

4. The University Extension Service has home 
economists and agricultural consultants also 
spread across the state and available for consul- 
tation to every rural family. 

5. The State Hospital system, under the Di- 
vision of Mental Diseases, offers the required 
help to the very sick, and wall be able to do much 
more consultative and preventive work as more 
personnel becomes available. 

These are the available resources. Now, what 
kinds of services would one like to be able to 
offer through these centers to the rural popula- 
tions and the people who five in small commu- 
nities throughout the state? They have of course 
the same kinds of problems in the area of mental 
health that all the rest have. For instance, there 
wall always be some people wffio are severely 
mentally ill and who wall need hospitalization. 
These people at present go to their local state 
hospitals. In the future they w 7 ill go to one of 
the three Rapid Treatment Centers for study 
and intensive help; but the problems of some of 
them will go on to the state hospitals, and some 
w 7 ill go directly back to the community. 

After they leave these hospitals and return 
home they need help and support from the fam- 
ily and community. It has been quite well shown 
by studies in Massachusetts 4 and elsew 7 here ;j that 
the more assistance these people get w hen they 
return home, from family, physicians, employers 
and others, the better they w 7 ill adjust and the 
fewer of them wall return to the hospital for 
further treatment. Many of these patients return 


196 


COMMUNITY HEALTH CENTERS— GILDEA 


Missouri Medicine 
March, 1964 


to their local doctors, but not all have the finan- 
cial resources for private care. The local doctor 
can do much more for these patients if his hand 
is strengthened by some kind of mental health 
worker to help the patient reintegrate in the 
community, in his job and his home. Many wel- 
fare workers do already assist in these followup 
services, and will be able to do so more effective- 
ly when centers are organized. In some states, 
Florida particularly, the discharged mental pa- 
tient is the charge of the health department, and 
followup is chiefly done by the public health 
nurse, who can be a valuable aid in after-care, 
both when the patient is ready to leave the hos- 
pital and after he is back home again. She is 
especially skilled in house calls, by traditional 
training. And she also will be able to do a more 
efficient job when she is supported by a mental 
health center. 

Next to consider is the whole array of adult 
maladjustments, some of which manifest them- 
selves in unusual or abnormal behavior and 
some in “nervousness” or physical illness. Pa- 
tients with these troubles will benefit enormously 
from help with their personal problems, and 
study of the whole situation: psychotherapy or 
counseling. This kind of service should be an 
important function of the center. It is often said 
that it will be a long time before a sufficient 
number of people are trained in psychotherapy 
or counseling to offer this service to the entire 
population, in enough areas spaced so that no 
one will have to travel more than an hour to get 
there. But I believe there are ways of utilizing 
short cuts in training ancillary personnel to offer 
these services under supervision. The National 
Institute for Mental Health has recently financed 
a study 6 on the training of mental health coun- 
selors in which housewives over 40 whose chil- 
dren have left home are offered an intensive 
course in psychotherapeutic technics. They have 
been found most useful in counseling services. 
Utilization of this kind of person may not be 
economical because it requires much training 
and supervision, but there is an enonnous pool 
of local talent hidden in homes where children 
have grown up and left. 

The central theme of preventive psychiatry is 
services for children. It has been apparent over 
the years that either traveling clinics, or clinics 
located where the patient must travel great dis- 
tances, can offer nothing more than diagnostic 
or consultation services and recommendations 
for children and their parents. When these men- 
tal health centers are established this will 
change. I would like to see a center in which 


there were a few beds (perhaps 20 or 25) avail- 
able for observation of children who are in acute 
difficulties. I would not propose that these should 
be used for any long-term treatment. Perhaps the 
maximum stay of any child would be two weeks. 
This should enable the local doctors, the center 
personnel, nurses, social workers and whatever 
psychiatric or psychological consultant is avail- 
able, to form an opinion about the child’s diffi- 
culties and the best way of dealing with them. 
For those children who are less ill but whose 
behavior is disturbed, I would like to see home 
visits made possible either by the nurse or social 
worker. One home visit contributes more under- 
standing to the unravelling of a child’s problems 
than three office visits, in many cases. 

However, the basic preventive service for chil- 
dren is the school mental health service, and this 
should be available to every school in the state, 
and should be a top priority service of these 
centers when they come into being. Since the 
school is the natural habitat for all children from 
6 to 16, this is the ideal spot for identification 
and study of the child’s problems and for help 
to be given before more stringent and expensive 
steps like individual counseling, psychotherapy 
or hospitalization become necessary. 

In the school mental health work done in St. 
Louis and St. Louis County, by far most has 
been done by social workers or psychiatric social 
workers who have acted as school counselors. In 
early work in St. Louis City 7 it was demonstrated 
that psychologists were effective as school coun- 
selors and also that one of these 40-year-old 
housewives was equally successful. 

I would like to see the development in this 
state of a job category called “mental health 
worker” or “mental health aide.” Long ago I 
proposed that a job category called “school men- 
tal health worker” be established. This person 
should have a bachelor’s degree, should be se- 
lected for interests, aptitudes and personality 
characteristics, and should be given one year of 
graduate training, the nature of which was dis- 
cussed with representatives of several different 
disciplines. The learning and experience which 
I would like to see this worker get in the one 
postgraduate year would be in interview tech- 
nics, personality development and parent-child 
relationships, and a review of school admin- 
istration, school policies, problems, curricula and 
organization. I then proposed that this one year 
graduate would work in the field under the close 
supervision of a more experienced school mental 
health worker with traditional training in social 
work or psychology. 


Volume 61 
Number 3 


COMMUNITY HEALTH CENTERS— GILDE A 


197 


This classification has been developed in Flor- 
ida. 8 People with a wide variety of previous ex- 
perience have been trained in mental health 
theories and technics and have been found most 
useful working in many community' activities, 
including schools. A report from the Florida 
State Board of Health tells how they have put 
their plan into action. They began with public 
health nurses, giving them in-service training 
in new ways of working with mental health spe- 
cialists. They designated their first mental health 
workers in 1954, and stated their initial qualifi- 
cations as “a bachelor’s degree or equivalent,” 
including in this general category a graduate de- 
gree from an accredited school of nursing. Re- 
lated experience was also required. The junior 
classification required two years of related ex- 
perience and the senior, five years. They inter- 
preted the type of experience required liberally. 
Any experience such as ordinarily obtained by a 
public health nurse, social worker or visiting 
teacher was at the top of the fist. Primary em- 
phasis was laid on finding mature, stable indi- 
viduals who have “pleasing personalities and a 
pioneering spirit.” I would add also a certain 
degree of aggressiveness, but capacity to control 
immediate hostile reactions. These workers were 
under the supervision of local health officers and 
state personnel, who had administrative respon- 
sibility for the worker, just as for other staff 
members. Senior consultants were always avail- 
able from the State Bureau of Mental Health. 

These workers in Florida are encouraged to 
develop programs in their areas along the lines 
of their special interests. In general, they have 
been involved in mental health education, which 
is a part of the general health education program 
of practically all local health departments. They 
have also been involved in “personal face-to-face 
helping” activities, which can certainly be sub- 
sumed under the general term, “counseling.” 
They are warned to avoid problems requiring 
“psychotherapy,” and it is said that counseling 
rarely exceeds six sessions, during which time 
the worker decides whether the case needs to 
be referred for professional assistance. These 
workers are involved in the programs of patients 
both in and released from mental hospitals. They 
participate not only in the followup programs, 
but also in the liaison work between the mental 
hospitals and the families of newly admitted pa- 
tients. Individual case work and home visiting 
are a common activity. 

Like others with more conventional training, 
these people can act as aides under supervision 
in all the school mental health service. They can 


receive referrals of children from school person- 
nel, and study the individual child’s difficulty in 
the school and visit when indicated in the home. 
In some schools the worker can sit with a teacher 
who is having special problems during class 
hours and give her immediate objective assist- 
ance with situations as they arise hour by hour 
and day by day, thereby sensitizing the teacher 
to the mental health problems of her charges 
and helping her to deal with these problems im- 
mediately. These workers can help to organize 
workshops, in-service training, or case confer- 
ences in every school all over the state, and can 
serve in this way a useful preventive as well as 
therapeutic purpose. 

Continual professional supervision of these 
workers is essential. The Florida group says that 
they have found in-service training to be valu- 
able with periodic work conferences and work- 
shops. Gradually, this group of people from 
differing backgrounds has become a homogene- 
ous, working force. A fully qualified social work- 
er or psychologist can multiply his usefulness 
many times with assistance such as aides like 
this can give. 

The systematic organization and development 
of these new Mental Health Centers, their direc- 
tion and staffing, is yet to be worked out. The 
actual form of each center should take its shape 
from the needs and resources in each community. 
A blueprint will not and should not be imposed 
by federal or state officials on each community. 
The grow'th, development and responsibility 
must come largely from the local resources and 
leadership, with consultation w 7 hen requested 
from any professional group. An executive com- 
mittee correlating this planning is now at w'ork. 
I feel sure we can look forward to a great new 
development in mental health services for the 
local communities in this state. 


Bibliography 

1. Donnelly, Ellen M., et al: A Cooperative Program Between 
State Hospital and Public Health Nursing Agency for Psychiat- 
ric After Care, J. Pub. Health 52:1084 (July) 1962. 

2. Belinson, Louis, and Morris, Ara L. : The Public Health 
Nurse, the Family and the Retarded Child, Mo. Med. 60:923 
(October) 1963. 

3. Scally, A. Lillian, and Tayback, Matthew: An Evaluation 
of Community Nursing Service in the Care of the Mentally 111, 
J. Pub. Health 53:1400 (September) 1963. 

4. Greenblatt, M. ; York, R., and Brown, E. L. : From Cus- 
todial to Therapeutic Patient Care in Mental Hospitals, Russell 
Sage Foundation, New York, 1955. 

5. Freeman, Howard E., and Simmons, Ozzie G. : The Mental 
Patient Comes Home, John Wiley & Sons, Inc., New York and 
London, 1963. 

6. Rioch, Margaret J., et al : National Institute of Mental 
Health Pilot Study in Training Mental Health Counselors, 
A. J. O. 33:678 (July) 1963. 

7. Gildea, Margaret C. L. : Community Mental Health : A 
School-Centered Program and a Group Discussion Program, 
Charles C Thomas, Springfield. 111.. 1959. 

8. Yeager, Wayne, et al : The Mental Health Worker : A New 
Public Health Professional, Am. J. Pub. Health 52 :1625 (Oc- 
tober) 1962. 



Kenneth C. Hollweg, M.D. 


President’s 

Message 



We physicians of the Missouri State Medical 
Association have a date with “togetherness.” 

“Togetherness” is a must for this most im- 
portant annual session of the Missouri State 
Medical Association. We all have things to talk 
about, complaints to air and matters to support. 
We all have ideas to exchange. 

We need to gain information from our col- 
leagues locally as well as from our colleagues far 
and wide so that we can obtain education from 
our excellent scientific program. 

Arrange to hear Dr. “Norm” Welch, our most 
able President-Elect of the American Medical 
Association — a treat to hear again if you have 
already heard and a treat to hear if you have not 
heard. He is the invited guest to speak at the 
annual banquet. 

See “you all” at the annual session, March 8 


to 1 1. 



EDITORIAL 


POPULATION AT THE MAIN 
PRODUCTIVE AGES 

About 85 million people in the United States, 
or almost 45 per cent of the total population, are 
in the age range from 25 to 64 years— the period 
of maximum productivity and family responsibil- 
ities, according to a report by the Metropolitan 
Life Insurance Company. This large segment of 
the population is expected to exceed 90 million 
by 1970 and reach 106 million in 1980. The 
growth between 1960 and 1970 will be moderate 
—8.5 per cent— but is expected to be twice as 
large in the following decade. 

This accelerated growth during the 1970’s will 
result largely from a sharp rise in the population 
at ages 25 to 34. As the record number of children 
born following the close of World War II pass 
their 25th birthday, the population in the 25 to 
34 age group is expected to increase from about 
25 million in 1970 to more than 36 million in 
1980, or by 45 per cent. This is nearly five times 
the growth anticipated for the 1960-1970 period. 
It is noteworthy that all of the increase at these 
ages in the 1960’s will occur after 1965; recently 
the population in this age group has actually 
been declining. 

The population at ages 35 to 44 will follow 
another course, reflecting the level of births pre- 
vailing 10 years earlier than that influencing the 
trend of the population at 25 to 34 years. In 1970 
there will be 1,100,000 fewer people at ages 35 to 
44 than there were in 1960. Between 1970 and 
1980, however, this age group will increase by 
2,100,000, reaching 25/4 million at the end of the 
decade. 

Still another growth pattern is expected for 
the population at ages 45 to 64. It appears that 
the number of people in this age group will in- 
crease by about one sixth between 1960 and 
1970, but by less than 5 per cent in the decade 
thereafter. This is the only age group in which 
the relative increase for females will exceed that 
for males— a result of the considerably greater 
depletion of men than women by mortality. 

At the time of the 1960 Census, more than 80 


per cent of the men and women aged 25 to 64 
were married. The proportion varied somewhat 
with sex and age. Among men it was about 82 
per cent at ages 25 to 34 and rose to 89 per cent 
for those 35 to 44 years; correspondingly, the 
proportion for bachelors decreased from 16 to 8 
per cent. Even at ages 45 to 64, the percentage 
married was only slightly below that at 35 to 44 
years, the decrease reflecting largely the marked 
rise in the number of widowers. 

In early adult life the proportion married is 
greater among women than it is among men. 
Thus, at ages 25 to 34 years in 1960, the married 
comprised about 88 per cent of all women. At 
ages 45 to 64, however, the proportion was slight- 
ly less than 74 per cent. The 2/4 million widowed 
at these ages constituted 15 per cent of all wom- 
en, or 4/2 times the proportion among men. Rela- 
tively more women than men were reported as 
divorced at each of the age periods under review. 

In the entire range of ages from early adult 
fife to the threshold of old age, the large majority 
of American men live with their wives in a house- 
hold of their own. This is the living arrangement 
of three fourths of all men at ages 25 to 34 and 
of more than four fifths of those in the next 30 
years of life. The proportion of women who are 
the head of a household increases from 7 per 
cent at ages 25 to 34 to 19 per cent at 45 to 64 
years. An appreciable number of men and women 
in the age range 25 to 64 years live in the house- 
hold of other relatives. Only a small proportion, 
however, live in institutions or other quarters. 

About 93 per cent of the men and 40 per cent 
of the women aged 25 to 64 years were in the 
labor force in April 1960. Among men, labor force 
participation was at a maximum in the age range 
25 to 44 years, when all but 5 per cent were em- 
ployed or seeking work. At 45 to 64 years the 
proportion was just below the 90 per cent mark. 
Among women, on the other hand, the relative 
number in the labor force increased from 35 per 
cent at ages 25 to 34 to about 42 per cent at ages 
35 to 64. This rise reflects the reentry of many 
women into the labor market after their children 
grow up. 


199 


Ramblings of the Field Secretary 


A large audience of physicians, their wives and 
guests attended the 129th Annual Meeting of the 
St. Louis Medical Society on Tuesday night, Jan- 
uary 7, where they witnessed an impressive cere- 
mony of the installation of officers for 1964. The 



St. Louis Medical Society installation ceremonies drew 
a large attendance. 


new officers installed were: Drs. David N. Kerr, 
President; Walter T. Gunn, President-Elect; 
R. W. Kelley, Vice President; R. V. Bradley, Sec- 
retary; C. H. Nicolai, H. A. Ritter and E. A. 


eluded refreshments, music for dancing and an 
appropriate atmosphere for socializing. 

The newly elected officers of the St. Louis 



Dr. Nakada, Mrs. Mayer and Dr. Mayer hear remarks 
of President Holhveg. 


County Medical Society for 1964 were installed 
at the Society’s installation dinner dance on 
Wednesday night, January 8, at Le Chateau, 
St. Louis County. Kenneth C. Hollweg, M.D., 
President of the MSMA, conducted the official 
installing procedure following a short talk to 




Drs. Kerr, Sherwin, Gunn and Kelley headed the 
receiving line. 


Dr. Sisk was seated between Mrs. Sisk and Mrs. 
Nakada at the head table. 


Powell, Councilors. Following a short talk sum- 
marizing some of the major activities of the Soci- 
ety during 1963, the retiring president, Dr. 
Charles S. Sherwin, turned over the gavel to Dr. 
Kerr. The new President, in his remarks, outlined 
a number of projects for the Society’s consider- 
ation during the present year. 

After the formal ceremonies were completed 
the President’s Reception added much to the 
evening’s festivities. This part of the program 
was arranged by the Woman’s Auxiliary and in- 


those assembled. These new officers included: 
Drs. James R. Nakada, President; James C. Sisk, 
President Elect; Stanley L. Harrison, Vice Pres- 
ident; C. Howe Eller, Secretary; Edmund V. 
Cowdry Jr., Robert A. Mayer and Paul W. Miles, 
Councilors. The evening festivities began with 
a social hour, followed by dinner and the more 
formal part of the program. At the conclusion of 
dinner, Dr. Robert A. Mayer, retiring President, 
introduced the many guests present and in his 
(Continued on page 244) 


200 





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neuromuscular reactions (extrapyramidal symp- 
toms) from the phenothiazine component in 
‘Eskatrol’ Spansule capsules. 

For complete prescribing information, please see 
PDR or available literature. 

Supplied: Bottles of 50 capsules. 

Smith Kline & French Laboratories ^ 



News — Personal and Professional 


“Communication” was the subject of a talk 
given by George J. Lytton, M.D., Kansas City, 
to a senior high school assembly at Pembroke 
Country Day School in December. 


The St. Louis Surgical Society will present the 
fortieth Hodgen Lecture at 6:00 p.m. on March 
3 at the St. Louis Medical Society Bldg. W. A. 
Altemeier, M.D., professor and chairman of the 
Department of Surgery, University of Cincinnati 
College of Medicine will speak on “Recent Stud- 
ies in the Nature and Control of Staphylococcal 
Enterocolitis Following Antibiotic Therapy.” 


Among recent associates selected by the Amer- 
ican College of Physicians are Richard A. Reider, 
M.D., and Emil F. Miskovsky, M.D., St. Louis; 
John I. Matthews, M.D., Jefferson City; Daniel 
L. Dolan, M.D., Springfield, and Paul C. Ves- 
cove Jr., Smithville. 


Recently elected officers of the Bethesda Gen- 
eral Hospital, St. Louis, are William H. Riley, 
M.D., president; Charles Sherwin, M.D., vice 
president, and Preston C. Hall, M.D., secretary. 


Recently elected officers of the medical staff 
of Christian Hospital, St. Louis, are Oliver E. 
Tjoflat, M.D., chief of staff; S. E. Pawol, M.D., 
associate chief, and Marion D. Bishop, M.D., 
secretary. 


The Southern Boone County Rt. 1 P.T.A., had 
as speaker early in January B. A. Moranville, 
M.D., Columbia, who discussed the Sabin oral 
polio vaccine. 


The staff of Missouri Baptist Hospital, St. 
Louis, recently elected Truman G. Drake, M.D., 
as chief of staff. Other staff officers elected are 
Robert A. Mayer, M.D., associate chief of staff; 
W. Edward Lansche, M.D., secretary, and Rich- 
ard A. Jones, M.D., treasurer. 


Late in January Bertrand D. Coughlin, M.D., 
was installed a member of the 12 member board 
of Notre Dame University. 


The medical staff of Alexian Brothers Hospital 
recently elected William Parker, M.D., as presi- 
dent of the staff. William Irvin, M.D., was 
named vice president, and Andrew Luh, M.D., 
secretary-treasurer. 


At a ceremony at St. Patrick’s Cathedral, New 
York, early in January Roy V. Boedeker, M.D., 
St. Louis, was invested as a Knight of Malta. 


At a meeting of the American Academy of 
Dermatology held in Chicago in December, 
Clinton W. Lane, M.D., was elected president of 
the organization. 


The Columbia Altrusa Club had as speaker at 
a January meeting H. M. Hardwicke, M.D., Jef- 
ferson City. He spoke on “A Home Nurse Pro- 
gram.” 


First speaker in a series of guest lectures 
scheduled for Kansas City General Hospital was 
William A. Knight Jr., M.D., St. Louis, who 
spoke on “The Physiological Basis for Screening, 
Diagnosis and Treatment of Pancreatic Disease.” 


“Electrocardiography” was the subject of a 
presentation by Michael Bemreiter, M.D., Kan- 
sas City, to the Greater Kansas City Academy of 
General Practice late in January. 


The South Central Business Association has 
elected John F. Bowser, M.D., Kansas City, to 
the board of governors for a two year term. 


The board of trustees of the Neurological Hos- 
pital, Kansas City, has reelected G. Wilse Robin- 
son Jr., M.D., Kansas City, president of the 
board. Dr. Robinson is medical director of the 
hospital. 


Addressing the Mark Twain P.T.A. at Leba- 
non, Rae W. Froelich, M.D., Lebanon, spoke on 
“P.T.A. Informs You of Your Child’s Health 
Needs.” 

(Continued on page 244) 


202 


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204 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
March, 1964 


MISSOURI STATE MEDICAL ASSOCIATION 
Hotel Chase, March 8-11, 1964 

106th Annual Session 

TIME AND PLACE OF MEETINGS 
Sunday, March 8 

12:30 p.m. Registration for House of Delegates, Lobby, Hotel Chase. 

1:30 p.m. House of Delegates, Khorassan Room. 

3:30 p.m. Reference Committee Meetings, Rooms Park, Coach, Colonial, Pal- 
ladian, English and Embassy. 

6:30 p.m. Committee on Diabetes and Missouri Diabetes Association Dinner 
Meeting, Stockholm Room, Park Plaza Hotel. 

Monday, March 9 

8:00 a.m. Registration, Lobby Floor, Hotel Chase. 

9:00 a.m. Scientific Session, Khorassan Room. 

10:30 a.m. Intermission to View Exhibits. 

11:00 a.m. Scientific Session, Khorassan Room. 

12:00 noon 50 Year Club Luncheon, Park Room. 

12:00 noon Committee on Maternal Welfare Luncheon, Regency Room. 

12:00 noon Luncheon Fireside Conference, Colonial Room. 

2:00 p.m. Scientific Session, Khorassan Room. 

2:00 p.m. Scientific Session, Lido, Room. 

3:00 p.m. Intermission to View Exhibits. 

4:00 p.m. House of Delegates, Khorassan Room. 

5:00 p.m. Reference Committees. 

5:00 p.m. Committee on Maternal Welfare, Eastern Division, St. Louis Med- 
ical Society Building. 

6:30 p.m. St. Louis Gynecologic Society Dinner, St. Louis Medical Society 
Building. 

6:30 p.m. Missouri Society of Internal Medicine Dinner, Stockholm Room. 
6:30 p.m. Missouri Radiological Society Dinner, Coach Room. 

6:30 p.m. Missouri Ophthalmological Society Dinner, Lido Room. 

6:30 p.m. Missouri Surgical Society Dinner, University Club. 

Tuesday, March 10 

8:00 a.m. Registration, Lobby Foor, Hotel Chase. 

9:00 a.m. Scientific Session, Khorassan Room. 

9:00 a.m. Scientific Session, Lido Room. 

10:30 a.m. Intermission to View Exhibits. 

11:00 a.m. Scientific Session, Khorassan Room. 

12:00 noon University of Missouri Medical Alumni Association Luncheon, 
Zodiac Room. 

1:30 p.m. Medical Economics Session, Khorassan Room. 

3:00 p.m. Intermission to View Exhibits. 

3:30 p.m. Scientific Session, Khorassan Room. 

3:30 p.m. Scientific Session, Lido Room. 

6:00 p.m. St. Louis University Medical Alumni Reception, Stockholm Room. 
6:00 p.m. Washington University Medical Alumni Reception, Coach Room. 
7:30 p.m. Annual Banquet in Honor of Past Presidents, Khorassan Room. 

Wednesday, March 11 

7:00 a.m. Registration, Lobby Floor, Hotel Chase. 

7:30 a.m. House of Delegates Breakfast Meeting, Chase Club. 


Better blood pressure 
response than with a 
thiazide alone 

“A dramatic potentiating 
hypotensive effect with 
excellent reductions in pres- 
sure was noted when syro- 
singopine [Singoserp] . . .was 
combined with hydrochloro- 
thiazide [Esidrix ].” 1 

Lower thiazide dosage 
“Hydrochlorothiazide 
[Esidrix] lowers the blood 
pressure, and its antihyper- 
tensive activity is poten- 
tiated by syrosingopine 
[Singoserp], allowing for a 
reduction of the dose of 
diuretic substance without a 
decrease in control of the 
disease .” 2 

Less risk of 
rauwolfia side effects 
“The combination of syro- 
singopine [Singoserp] and 
hydrochlorothiazide 
[Esidrix] not only has the 
hypotensive effects of reser- 
pine and hydrochlorothia- 
zide but has the added 
advantage of causing fewer 
side-effects .” 3 


Indications: Mild to moder- 
ate hypertension, especially 
when complicated by edema. 


Average Dosage: 1 Tablet #2 
(syrosingopine 1 mg./hy- 
drochlorothiazide 25 mg.) 
t.i.d. For patients requiring 
less syrosingopine, substi- 
tute Tablet #1 (syrosingo- 
pine 0.5 mg. /hydrochloro- 
thiazide 25 mg.) . 

Side Effects & 
Precautionary Measures 

Singoserp ( syrosingopine ): 
Use cautiously in patients 
with peptic ulcer. Discon- 
tinue several weeks prior to 
surgery, if possible. 
Occasional side effect : nasal 
congestion. Rare side effects: 
gastric irritation, drowsi- 
ness, fatigue, nausea, head- 
ache, emotional depression, 
skin rash, restlessness, 
anxiety. 

Esidrix (hydrochlorothia- 
zide): Watch for signs of 
fluid or electrolyte imbal- 
ance. Further electrolyte 
depletion may cause hypo- 
chloremic alkalosis and 
hypokalemia. Since the lat- 
ter may precipitate digitalis 
intoxication, watch care- 
fully patients taking digi- 
talis or its glycosides. 

Pay special attention to 
electrolyte balance of pa- 
tients with severe renal or 
hepatic insufficiency. In 
patients with cirrhosis and 


ascites, watch for symptoms 
of impending hepatic coma. 
Contraindicated in patients 
with oliguria and complete 
renal shutdown. 

Rare reactions : purpura 
with or without thrombocy- 
topenia, skin rash, photo- 
sensitivity, urticaria. Thia- 
zides may decrease glucose 
tolerance ; use cautiously in 
diabetics. Hyperuricemia 
may occur but is readily 
reversed by a uricosuric 
agent. 

Occasional side effects: 
nitrogen retention (in hyper- 
tensive patients), nausea, 
anorexia, headache, restless- 
ness, constipation. 

Supplied 

Tablets # 2 (white), each con- 
taining 1 mg. syrosingopine 
and 25 mg. hydrochlorothia- 
zide ; Tablets # 1 (white), 
each containing 0.5 mg. syro- 
singopine and 25 mg. hydro- 
chlorothiazide. 

References 

1. Kolodny, A. L., and Dabo- 
lins, R. : Angiology 11 :180 
(June) 1960. 

2. Bare, W. W. : J. Amer. 
Geriat. Soc. 5:795 (Oct.) 
1960. 

3. Lisan, P., and Balaban, S. 
A. : J. Amer. Geriat. Soc. 
5:803 (Oct.) 1960. 


Singoserp 8 -Esidrix s 

(syrosingopine and hydrochlorothiazide CIBA) 


G I B A Summit, N.J. 


2 /S 181 MK 


208 


ORGANIZATION ACTIVITIES 

MISSOURI STATE MEDICAL ASSOCIATION 
Preliminary Program 
106th Annual Session 
Hotel Chase, St. Louis 
March 8, 9, 10, 11, 1964 


12:30 p.m. 
1:30 p.m. 
3:00 p.m. 
3:00 p.m. 
3:30 p.m. 
4:00 p.m. 
4:30 p.m. 
4:45 p.m. 
4:45 p.m. 
6:30 p.m. 


8:00 a.m. 
9:00 a.m. 


10:30 a.m. 
11:00 a.m. 


12:00 noon 


12:00 noon 


12:00 noon 


Sunday, March 8, 1964 

Registration of Delegates. Lobby floor. 

House of Delegates, Khorassan Room. 

Reference Committee meetings. 

Reports of Officers, Coach Room. 

Constitution and By-laws, Park Room. 

Miscellaneous Affairs, Palladian Room. 

Resolutions, Colonial Room. 

Medical Education and Public Welfare, Embassy Room. 

Necrology, English Room. 

Missouri Diabetes Society dinner meeting, Stockholm Room. 

H. E. Oppenheimer, M.D., Clayton, presiding. 

Relationship Between Severity of Diabetes and Insulin Secretory 
Reserves, Holbrooke S. Seltzer, M.D., Dallas, Tex. 

Monday, March 9, 1964 

Registration. Lobby floor. 

Panel: What’s New, Khorassan Room. 

Moderator: Thomas F. Frawley, M.D., St. Louis. 

New Trends in Medicine: William D. Davis Jr., M.D., New 
Orleans. 

New Trends in Surgery: Thomas L. Marchioro, M.D., Denver. 
New Trends in Allergy: Charles W. Parker, M.D., St. Louis. 

New Trends in ENT: John J. Shea, M.D., Memphis, Tenn. 

Intermission to View Exhibits. 

Panel: Current Concepts in Treatment of Chronic Renal Disease, 
Khorassan Room. 

Moderator: C. Thorpe Ray, M.D., Columbia. 

Problems Involved in an Artificial Kidney Center Devoted Solely 
to Chronic Dialysis, F. K. Curtis, M.D., Seattle. 

Some Problems Involved in Human Homo-transplantation, Thomas 
L. Marchioro, M.D., Denver. 

50 Year Club Luncheon, Park Room. 

M. K. Underwood, M.D., Rolla, presiding. 

J. H. McCurry, M.D., Cash, Ark., Secretary, Fifty Year Club of 
American Medicine, Guest. 

Committee on Maternal Welfare Luncheon, Regency Room. 

A. C. Trueblood, M.D., Clayton, presiding. 

Speaker: Arthur L. Haskins, M.D., Baltimore, Md. 

Luncheon Fireside Conference, Colonial Room. 

Vagrant Acid Fast Organisms in Pulmonary Disease: The Physician’s 
Dilemma. 

Moderator: Karl H. Pfuetze, M.D., Hinsdale, 111. 

Panelists : 

Raymond F. Corpe, M.D., Rome, Ga. 


Missouri Medicine 
March, 1964 


Volume 61 
Number 3 


ORGANIZATION ACTIVITIES 


209 


Ernest H. Runyon, Ph.D., Salt Lake City, Utah. 

John H. Seabury, M.D., New Orleans, La. 

Henry C. Sweany, M.D., Mount Vernon, Mo. 

Sponsored by the Missouri Chapter, American College of Chest 
Physicians. 

Medical Session, Lido Room. 

2:00 p.m. Panel: Liver Disease. 

Moderator: Robert E. Koch, M.D., St. Louis. 

Problems in Treatment of Cirrhosis, William D. Davis Jr., M.D., 
New Orleans. 

Sponsored by the Missouri Society of Internal Medicine. 
Hemochromatosis, Holbrooke S. Seltzer, M.D., Dallas, Tex. 
Sponsored by the Missouri Diabetes Society. 

Current Problems in Hepatitis, Hyman J. Zimmerman, M.D., Chica- 
go. 

Surgical Session, Khorassan Room. 

Paul F. Max, M.D., St. Louis, presiding. 

2:00 p.m. Regional Enteritis— Surgical Aspects, B. Marden Black, M.D., 
Rochester, Minn. 

Sponsored by the Missouri Surgical Society. 

2:30 p.m. The Chiari Frommel Syndrome (Medroxyprogesterone Acetate 
Therapy), Arthur L. Haskins, M.D., Baltimore, Md. 

Sponsored by the St. Louis Gynecologic Society. 

3:00 p.m. Care of the Child With Multiple Injuries, John C. Wilson Jr., Los 
Angeles. 

3:30 p.m. Intermission to View Exhibits. 

4:00 p.m. House of Delegates. 

5:00 p.m. Reference Committee meetings. 

5:00 p.m. Committee on Maternal Welfare, Eastern Division, St. Louis Med- 
ical Society Building. 

6:30 p.m. St. Louis Gynecologic Society dinner meeting, St. Louis Medical 
Society Bldg. 

6:30 p.m. Missouri Surgical Society dinner meeting, University Club. 

6:30 p.m. Missouri Ophthalmological Society dinner meeting, Lido Room. 

6:30 p.m. Missouri Radiological Society reception and dinner meeting, Coach 
Room. 

6:30 p.m. Missouri Society of Internal Medicine, Stockholm Room. 

Tuesday, March 10, 1964 
8:00 a.m. Registration. Lobby floor. 

9:00 a.m. Panel: Hits and Misses in Current Drug Therapy, Khorassan Room. 
Moderator: Edward D. Kinsella, M.D., St. Louis. 

Cancer Chemotherapy, C. Gordon Zubrod, M.D., Bethesda, Md. 
The Use of Thyroid, Thyroxine and Triido-thyronine in the Treat- 
ment of Hypothyroidism and Other Conditions, Paul H. 
Lavietes, M.D., New Haven, Conn. 

MAO Inhibitors, Their Use, Misuse and Therapeutic Effects, 
Nathan S. Kline, M.D., Orangeburg, N. Y. 

9:00 a.m. Panel: Adolescent Medicine, Lido Room. 

Adolescent Obesity: Metabolic or Psychologic? Felix P. Heald Jr. 
M.D., Washington, D. C. 

Emotional Problems in Adolescence, Robert J. Corday, M.D., St. 
Louis. 

Precocious Puberty, Willard M. Allen, M.D., St. Louis. 

10:30 a.m. Intermission to View Exhibits. 

Carl R. Ferris, M.D., Kansas City, presiding. 


210 ORGANIZATION ACTIVITIES 

11:00 a.m. Anatomy of Experimentally Produced Hydrocephalus, M. D. Over- 
holser, M.D., Columbia. 

Missouri University Medical Award Winner. 

11:30 a.m. Polyglandular Disease and Its Relationship to Peptic Ulcer, Edwin 
H. Ellison, M.D., Milwaukee, Wis. 

12:00 noon University of Missouri Medical Alumni Association Luncheon, 
Zodiac Room. 

Wyeth Hamlin, M.D., Hannibal, President, presiding. 

1:30 p.m. Medical Economics Session, Khorassan Room. 

The Problem of Hospital Costs. 

Moderator: James P. Murphy, M.D., St. Louis. 

Panelists: 

Mr. Harry M. Piper, St. Louis, Administrator of St. Luke’s 
Hospital. 

Mr. John B. Warner Jr., St. Louis, Director of St. Louis Uni- 
versity Hospitals. 

Frank R. Bradley, M.D., St. Louis, Director Emeritus, Barnes 
Hospital. 

Morris Alex, M.D., St. Louis. 

Charles A. Nester, M.D., St. Louis. 

3:00 p.m. Intermission to View Exhibits. 

3:30 p.m. Panel: Treatment of Hiatus Hernia and Esophagitis, Lido Room. 
Moderator: Hector W. Benoit Jr., M.D., Kansas City. 

Panelists: 

Donald B. Effler, M.D., Cleveland, Ohio. 

Nicholas C. Hightower, M.D., Temple, Tex. 

Richard Schatzki, M.D., Boston, Mass. 

3:30 p.m. Panel: Long Term Management of Ischemic Heart Disease, Kho- 
rassan Room. 

Moderator: Guy D. Callaway Jr., M.D., Springfield. 

Coronary Arteriography: Clinical and Physiological Correlations, 
Richard S. Ross, M.D., Baltimore, Md. 

Impending Myocardial Infarction, R. E. Beamish, M.D., Winnipeg, 
Canada. 

Prophylactic Anticoagulent Therapy After Myocardial Infarction, 
Herbert E. Griswold Jr., M.D., Portland, Oregon. 

Sponsored by the Missouri Heart Association. 

5:45 to 7:15 p.m. St. Louis University Medical Alumni Reception, Stock- 
holm Room. 

6:00 to 7:15 p.m. Washington University Medical Alumni Reception, Coach 
Room. 

7:30 p.m. Banquet in Honor of Past Presidents, Khorassan Room. 

Kenneth C. Hollweg, M.D., Kansas City, President, presiding. 
Speaker: Norman A. Welch, M.D., Boston, President-Elect, Amer- 
ican Medical Association. 

Wednesday, March 11, 1964 

7:30 a.m. House of Delegates Breakfast Meeting, Chase Club. 


Missouri Medicine 
March, 1964 



How can JOHNSON'S Baby Lotion help 
the doctor, the mother and the baby? 


The doctor knows the young mother wants 
to do everything in her power to keep her 
baby clean and happy and in good health. 

And more and more evidence points to the 
tact that the physical expression of her love 
for her baby is not only a delight to the 
mother and pleasant for her child, but an 
essential element in the development of a mature, 
self-reliant adult.* A father as well as a physician, 
he knows that Johnson's Baby Lotion not only makes 
changing diapers easier and more pleasant for all 
concerned, but that the antibacterial effect of its 


hexachlorophene content (0.5%) persists for 
days, to protect the baby's delicate skin from 
rashes and infections. With Johnson's Baby 
Lotion normal skin functions are unaltered 
because the protective film is aqueous rather 
than occlusively oily. These are some of the 
reasons so many physicians recommend 
Johnson's Baby Lotion for routine use to protect deli- 
cate skin. May we send you samples of this superior 
antibacterial emollient in the convenient new plastic 
bottle? 

*DonnelIy, J.: A.M.A. Arch. Environmental Health 6:697, June, 1963 



ymron Jjfvtvmxw 


New Brunswick, N. J. 


© J&J. 'M 


212 ORGANIZATION ACTIVITIES 

DELEGATES 

County Society Delegates Alternates 

Andrew Forrest Long, Savannah Warren C. Baker, Savannah 

Audrain Harry F. O’Brien, Mexico B. N. Jolly, Mexico 

Barton-Dade .... Herbert Arnold, Lamar Thomas Carroll, Lamar 

Barton-Dade. . . . 

Benton James A. Logan, Warsaw 

Boone James C. Cope, Columbia Leroy J. Miller, Columbia 

Boone Hugh E. Stephenson, Columbia . Thomas W. Burns, Columbia 

Boone C. Thorpe Bay, Columbia John T. Logue, Columbia 

Buchanan John N. Martin, St. Joseph E. F. Butler, St. Joseph 

Buchanan Ernest E. Wadlow, St. Joseph. T. E. Potter, St. Joseph 

Butler-Ripley- 

Wayne Fred J. Biggs Jr., Poplar Bluff. . E. T. Hansbrough, Poplar 

Bluff 

Butler-Ripley- 

Wayne Gene Leroux, Doniphan Frank C. Johnson, Doniphan 

Butler-Ripley- 

Wayne Harold H. Cline, Piedmont 

Callaway James Ritterbusch, Fulton James Hill, Fulton 

Cape Girardeau . . 

Carter-Shannon. . 

Carter-Shannon. . 

Chariton-Macon- 

Monroe- 

Randolph F. L. Harms, Salisbury D. D. Stuart, Brunswick 

Chariton-Macon- 

Monroe- 

Randolph James E. Campbell, Macon . Howard Miller, Macon 

Chariton-Macon- 

Monroe- 

Randolph F. A. Barnett, Paris G. M. Ragsdale, Paris 

Chariton-M acon- 
Monroe- 

Randolph A. P. Rowlette, Moberly Robert Hasson, Moberly 

Clay E. H. Fischer, N. Kansas City. Jas. W. Willoughby, Liberty 

Clay R. D. Dwyer, N. Kansas City. . . Paul Revare, N. Kansas City 

Clinton J. P. Mabrey, Plattsburg P. T. Luckenbill, Plattsburg 

Cole G. D. Shull, Jefferson City Byron Watts, Jefferson City 

Cooper G. W. Winn, Boonville 

Dallas-Hickory- 

Polk O. A. Griffin, Buffalo Evelyn Griffin, Buffalo 

Dallas-Hickory- 

Polk 

Dallas-Hickory- 

Polk Ben Koon, Bolivar Geo. Robinson, Humansville 

Dunklin Joe A. Zimmerman, Kennett. . . .George Dunmire, Kennett 

Franklin-Gascon- 
ade-Warren . William Richardson, Union James Shea, Gerald 

Franklin-Gascon- 
ade-Warren George M. Workman, Hermann . Paul Brenner, Owensville 
F ranklin-Gascon- 

ade-Warren . H. H. Schmidt, Washington. . . . Harold Hoelscher, Warrenton 
Grand River 

Caldwell Frank Daley, Hamilton Howard Carter, Hamilton 

Livingston. . . .Virgil Vandiver, Chillicothe. . . . William Fair, Chillicothe 

Grundy Chester Clark, Trenton A. Cross, Trenton 

Davies Fred Wilson, Winston Larry Dowell, Pattonsburg 

Harrison W. A. Broyles, Bethany G. P. Sutherland, Bethany 

Linn J. R. Dixon, Brookfield George Gary, Marceline 

Mercer Frank Zahrt, Princeton 

DeKalb James Sweiger, Maysville 

Carroll E. W. Allen, Carrollton R. Staton, Carrollton 


Missouri Medicine 
March, 1964 


Volume 61 
Number 3 


ORGANIZATION ACTIVITIES 

County Society Delegates Alternates 

Greene Stanley S. Peterson, Springfield. . Wm. C. Francis, Springfield 

Greene Edwin M. Powell, Springfield. . . M. J. Clarke, Springfield 

Greene Kenneth E. Knabb, Springfield. . Robt. W. Maher, Springfield 

Greene William H. Snead, Springfield. . . H. J. McAlhany, Springfield 

Henry Shelby Hughes, Clinton J. O. Smith, Clinton 

Howard Donald Wells, Glasgow William A. Bloom, Fayette 

Jackson B. W. Andrews, Kansas City. . . . Arthur Adelman, Kansas City 

Jackson John F. Bowser, Kansas City. . . . Pat A. Barelli, Kansas City 

Jackson Philip L. Byers, Kansas City. . . . J. L. Barnard Jr., Kansas City 

Jackson Dillard M. Eubank, Kansas City. Neil Berry, Kansas City 

Jackson Robert Forsythe, Kansas City. . . Richard Blim, Kansas City 

Jackson Harold Gainey, Kansas City. . . . C. S. Cooper, Kansas City 

Jackson William W. Gist, Kansas City. . . H. V. Davis, Kansas City 

Jackson John A. Griffith Jr., Kansas City . John A. Flatley, Kansas City 

Jackson Wm. M. Kitchen, Kansas City. . Fred D. Fowler, Kansas City 

Jackson Jas. R. McVay Jr., Kansas City. . John B. Justus, Kansas City 

Jackson Gerald L. Miller, Kansas City. . . Ray. Keltner, Kansas City 

Jackson William C. Mixson, Kansas City. Geo. L. Lytton, Kansas City 

Jackson Ralph Perry, Kansas City K. S. Nicolay, Kansas City 

Jackson Russell D. Shelden, Kansas City. Ira T. Smith, Kansas City 

Jackson A. Lloyd Stockwell, Kansas City. Harry Statland, Kansas City 

Jackson C. B. Wheeler Jr., Kansas City. . C. L. Thompson, Kansas City 

Jasper M. Foster Whitten, Carthage. . . R. R. Cohle, Carthage 

Jasper G. A. Schulte, Joplin Virgil Jeans, Joplin 

Jefferson F. L. Kozal, Crystal City W. T. Judge, Crystal City 

Johnson Chas. M. Lederer, Warrensburg. 

Lafayette-Ray . . Joe Ward, Lexington William LaHue, Lexington 

Lafayette-Ray . . George Davault, Richmond Isadore Goldberg, Braymer 

Lewis-Clark- 

Scotland Landis Y. Davis, Canton 

Lewis-Clark- 

Scotland 

Lewis-Clark- 

Scotland Earl E. Gilfillan, Memphis 

Lincoln-St. 

Charles E. O. Damron, Elsberry Louis Hetlage, Troy 

Lincoln-St. 

Charles Paul Rother, St. Charles Robert Keller, Wentzville 

Marion-Ralls- 

Shelby Merrill J. Roller, Hannibal D. B. Landau, Hannibal 

Marion-Ralls- 

Shelby 

Marion-Ralls- 

Shelby 

Mid-Missouri 

Phelps W. R. Lytle, Rolla Barbara E. Russell, Rolla 

Crawford A. R. Bauman, Steelville F. A. Elders, Cuba 

Dent B. J. Bass, Salem M. M. Hart, Salem 

Pulaski Clyde Miller, Waynesville 

Maries 

Laclede Rae W. Froelich, Lebanon G. E. Fisher, Lebanon 

Miller 

Mineral Area 

St. Francois. . R. A. Huckstep, Farmington. . . . C. H. Appleberry, 

Rivermines 

Iron Ben Bull, Ironton William Patton, Ironton 

Madison M. Grossman, Fredericktown. . . C. Michaelis, Fredericktown 

Washington. . George Cresswell, Potosi Tom Warren, Poplar Bluff 

Reynolds 

Moniteau Richard Fulks, California K. S. Latham, California 

Montgomery . . . . E. J. T. Anderson, Montgomery 

City S. J. Byland, Wellsville 

Morgan Jack Gunn, Versailles J. L. Washburn, Versailles 


213 


214 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
March, 1964 


County Society 

Nodaway-Holt- 
Atchison- 
Gentry- Worth 
Nodaway-Holt- 
Atchison- 
Gentry- Worth 
Nodaway-Holt- 
Atchison- 
Gentry- Worth 
Nodaway-Holt- 
Atchison- 
Gen try- Worth 
Nodaway-Holt- 
Atchison- 
Gentry- Worth 
North Central 

Adair 

Schuyler 

Knox 

Sullivan 

Putnam 

Ozarks 

Barry 

Lawrence .... 

Stone 

Christian 

Taney 

Newton 

McDonald 

Pemiscot 

Perry-Ste. 

Genevieve. . . 
Perry-Ste. 
Genevieve 

Pettis 

Pike 

Platte 

St. Louis City 
St. Louis City 
St. Louis City 
St. Louis City . . . 
St. Louis City. 

St. Louis City 
St. Louis City. 

St. Louis City 
St. Louis City . . . 
St. Louis City 
St. Louis City. 

St. Louis City 
St. Louis City . 

St. Louis City . . 
St. Louis City. . . 
St. Louis City. . . 
St. Louis City. . . 
St. Louis City. . 
St. Louis City. . 
St. Louis City. . 
St. Louis City. . . 
St. Louis City . . . 
St. Louis City. . . 
St. Louis City. . . 
St. Louis City. . . 
St. Louis City. . . 
St. Louis City. . 
St. Louis 


Delegates 

E. D. Imes, Maryville 

J. Humphrey, Mound City. 

E. L. Neidermeyer, Tarkio 

A. L. Carlin, Stanberry 

Frank Matteson, Grant City 
E. M. Grim, Kirksville. . 
Francis Tarvydas, Edina 


Alternates 

R. E. Dunshee, Maryville 
D. C. Perry, Mound City 
W. Carpenter, Rock Port 


S. L. Freeman, Kirksville 
. W. B. Isom, Knox City 


W. J. Glass, Monett Mary Newman, Cassville 

Kenneth Glover, Mount Vernon Allen Bailey, Mount Vernon 

Fred Wommack, Crane 

Stanley Roper, Ozark 

Roy Gillespie, Branson William Magness, Branson 

Paul B. Anderson, Neosho G. W. Blankenship, Neosho 

O. W. Cook, Caruthersville Daniel Hensley, Lilboum 

O. A. Carron, Perryville J. F. Fairchild, Perryville 

J. Lutkewitte, Ste. Genevieve. . . G. H. DeGenova, Ste. 

Genevieve 

Gordon Stauffacher, Sedalia .... A. L. Lowe, Sedalia 
Lawrence Stuerman, Louisiana. . R. F. Christensen, Louisiana 

Sam Allen, Parkville Albert Lewis, Platte City 

Henry C. Allen, St. Louis D. A. Bindbeutel, St. Louis 

Robert B. Bassett, St. Louis. . . . 

Richard V. Bradley, St. Louis . . . Edwin C. Ernst Jr., St. Louis 

John P. Eberle, St. Louis Joseph C. Edwards, St. Louis 

William P. Gillespie, St. Louis . . 

Charles Gulick, St. Louis Ed. M. Cannon, St. Louis 

Walter T. Gunn, St. Louis S. F. Hampton, St. Louis 

Leo J. Hartnett, St. Louis C. Alan McAfee, St. Louis 

George L. Hawkins, St. Louis. . . 

Robert W. Kelley, St. Louis . . Dallas J. Dyer, St. Louis 

David N. Kerr, St. Louis Lee T. Ford Jr., St. Louis 

Edward D. Kinsella, St. Louis. John B. Shapleigh, St. Louis 

Louis H. Kohler, St. Louis Richard L. Sterkel, St. Louis 

Warren M. Lonergan, St. Louis . Oliver E. Tjoflat, St. Louis 

J. Otto Lottes, St. Louis V. T. Houston, St. Louis 

J. W. Berry, St. Louis Robert E. Funsch, St. Louis 

Paul F. Max, St. Louis Martin G. Austin, St. Louis 

William F. Melick, St. Louis. . .Joshua E. Jensen, St. Louis 
Albert M. Repetto, St. Louis . . .Louis T. Litzow, St. Louis 

M. S. Franklin, St. Louis N. Knowlton Jr., St. Louis 

Charles S. Sherwin, St. Louis. . . Carl J. Dreyer, St. Louis 

Jerome I. Simon, St. Louis Charles O. Metz, St. Louis 

Don C. Weir, St. Louis John E. Byrne, St. Louis 

Herbert Wiegand, St. Louis Louis E. Keller, St. Louis 

Charles R. Doyle, St. Louis 

J. L. Lucido, St. Louis Charles B. Ladd, St. Louis 

D. Elliott O’Reilly, St. Louis. . . . W. C. MacDonald, St. Louis 
James R. Nakada, St. Louis R. E. Catanzaro, St. Louis 


Volume 61 
Number 3 


ORGANIZATION ACTIVITIES 


215 


County Society Delegates Alternates 

St. Louis James C. Sisk, St. Louis Jack R. Eidelman, St. Louis 

St. Louis William H. Bailey, St. Louis. . . M. G. Fingerhood, St. Louis 

St. Louis Edgar W. Davis, St. Louis Ed. C. Holscher, St. Louis 

St. Louis Falls B. Hershey, St. Louis Victor T. Jones, St. Louis 

St. Louis Richard A. Sutter, St. Louis . . Allen P. Klippel, St. Louis 

St. Louis Maurice A. Diehr, St. Louis. . . . Charles Miller Jr., St. Louis 

St. Louis Louis F. Howe, St. Louis Hanford Phillips, St. Louis 

St. Louis Joseph B. Kendis, St. Louis M. M. Schwartz, St. Louis 

St. Louis Robert A. Mayer, St. Louis Miles C. Whitener, St. Louis 

Saline C. A. McBurney, Slater E. Lee McCorkle, Marshall 

SEMO 

Stoddard . Ralph Rehm, Bloomfield Richard Comeau, Dexter 

New Madrid . . Samuel Sarno, Morehouse Chas. Reeder, New Madrid 

Mississippi. . John Dernoncourt, Charleston Robert Frazier, Charleston 

Scott A. P. Sargent, Sikeston William O. Finney, Chaffee 

South Central 

Howell John E. Wilson, West Plains. . . H. Miller, Willow Springs 

Oregon C. W. Cooper, Thayer A. T. Walker, Mammoth 

Springs, Ark. 

Texas Joe Wall, Houston James A. Hasek, Cabool 

Wright R. W. Denney, Mountain Grove. 

Douglas Marvin Gentry, Ava 

Ozark 

Webster T. M. Macdonnell, Marshfield . 

West Central 

Bates Arthur Hansen, Butler Carter Luter, Butler 

Cass Edward Jones, Harrisonville . . . . Alfred Eklund, Pleasant Hill 

Cedar R. Magee, El Dorado Springs . . . William Richter, Stockton 

St. Clair Donald Giesler, Osceola Robert Brownsberger, 

Appleton City 

Vernon Rolla Wray, Nevada Roy Pearse, Nevada 


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216 ORGANIZATION ACTIVITIES 

MISSOURI SOCIETY OF MEDICAL TECHNOLOGISTS 
Seventeenth Annual Convention 
March 8, 9, 10, 11, 1964 

March 8, 1964, Firmin Desloge Hospital, Miller Hall 

2:00 p.m. Business Meeting, Missouri Society of Medical Technologists. 

6:00 p.m. Buffet Supper, Cafeteria. 

8:00 p.m. Business Meeting, Missouri Association of Blood Banks. 

CHASE-PARK PLAZA HOTEL, STOCKHOLM ROOM 
March 9, 1964, Missouri Association of Blood Banks 

9:00 a.m. Invocation, Rev. J. Willis Averill, S.J., St. Louis. 

9:05 a.m. Address of Welcome, Thomas J. Cooper, M.D., President, MABB. 

9:10 a.m. The Resolution of Incompatible Crossmatches, Marjorie Stroup, 
M.T. (ASCP), Ortho Research Foundation, Raritan, N. J. 

9:50 a.m. River of Life, Narrated by J. P. Soulier, M.D., Paris. 

10:10 a.m. Coffee Break. 

10:30 a.m. Lectins, Nancy Allen, B.A., Research Immunohematologist, Hyland 
Laboratories, Los Angeles. 

11:15 a.m. 15-, 30-, or 60-Minute Incubations?, Sally Frank, M.T. (ASCP), 
B.B., Assistant Supervisor, Consultation Laboratories, Dade 
Reagents, Inc., Miami. 

12:00 noon Question-Answer Panel. Moderator: Eugene F. Tucker, M.D., Di- 
rector of Laboratories, St. Mary’s Hospital, St. Louis. 

Missouri Society of Medical Technologists 

2:00 p.m. Address of Welcome, Marian Winter, M.T. (ASCP), President, 
MSMT. 

2:05 p.m. Radiobiology, Armand E. Brodeur, M.D., Radiologist, Cardinal 
Glennon Memorial Hospital for Children, St. Louis. 

2:45 p.m. Review of Thalassemia Major, Judith Callier, Student, St. Louis. 

3:00 p.m. Coffee Break. View Exhibits. 

3:30 p.m. A General Review of Aplastic Anemia, Diane Wulfert, Student, 
St. Louis. 

3:45 p.m. (To be announced. ) 

6:30 p.m. Social Hour, Sponsored by Aloe Scientific. 

7:30 p.m. Banquet, Stan Musial and Biggie’s Restaurant, 5130 Oakland, St. 
Louis. 

March 10, 1964 

9:00 a.m. Laboratory Diagnosis of Viral Diseases, Lt. Col. Samuel T. Waid, 
Chief, Virology Division, 5th U. S. Army Medical Laboratory, 
St. Louis. 

10:00 a.m. Coffee Break. View Exhibits. 

10:30 a.m. Autoimmunity and Antibody Formation, R. William Burmeister, 
M.D., Associate Section Head, Unit II Medicine, St. Louis 
City Hospital, St. Louis. 

11:30 a.m. Microbial Ecology in Man, Alex C. Sonnenwirth, Ph.D., Director, 
Division of Microbiology, Jewish Hospital; Assistant Profes- 
sor, School of Medicine, Washington University, St. Louis. 

2:00 p.m. (Subject to be announced), John P. Wyatt, M.D., Director and 
Professor, Department of Pathology, St. Louis University 
School of Medicine, St. Louis. 

3:00 p.m. Coffee Break. 

3:15 p.m. The Multiple Technic Concept: Its Application to Pulmonary 
Function, Vernon W. Fischer, B.S., M.T. (ASCP), Chief His- 
tology Technician, St. Louis University, St. Louis. 

3:45 p.m. Administrative and Personnel Problems in Medical Technology, 
W. I. Christopher, B.A., M.H.A., Director of Research and 
Personnel Services; Staff Assistant, Committee on Medical 
Technology, Catholic Hospital Association, St. Louis. 

5:30 p.m. Sisters Dinner, Stan Musial and Biggie’s Restaurant. 


Missouri Medicine 
March, 1964 


Volume 61 
Number 3 


ORGANIZATION ACTIVITIES 


217 


TECHNICAL EXHIBITS 

Abbott Laboratories, North Chicago, III. Booth 6. 

C. W. Alban & Co., St. Louis, Mo. Booth 38. 

Aloe, Division of Brunswick Corp., St. Louis, Mo. Booth 8. 

American Medical Association, Chicago, III. Booth 20A. 

Arnar-Stone Laboratories, Inc., Mount Prospect, III. Booth 25. 

Astra Pharmaceutical Products, Inc., Worcester, Mass. Booth 45. 
Automatic Medical Systems of Missouri, Inc., Omaha, Nebr. Booth 16. 
Ayerst Laboratories, New York, N. Y. Booth 9. 

Ciba Pharmaceutical Company, Summit, N. J. Booth 7. 

The Coca-Cola Company, Atlanta, Ga. Booth 20. 

Dome Chemicals, Inc., New York, N. Y. Booth 50. 

Donley-Evans & Co., St. Louis, Mo. Booth 48. 

The Doyle Pharmaceutical Company, Minneapolis, Minn. Booth 47. 
Dumas-Wilson & Co., St. Louis, Mo. Booth 2. 

Eli Lilly and Company, Indianapolis, Ind. Booth 39. 

The Emko Company, St. Louis, Mo. Booth 42. 

Encyclopaedia Britannica, Chicago, III. Booth 43. 

Geigy Pharmaceuticals, Yonkers, N. Y. Booth 49. 

Hamilton-Schmidt Surgical Co., St. Louis, Mo. Booth 23. 

Maico Company, Inc., St. Louis, Mo. Booth 33. 

Mead Johnson Laboratories, Evansville, Ind. Booth 41. 

Medco Products Company, Tulsa, Okla. Booth 28. 

Medical Arts Services, Inc., St. Louis, Mo. Booth 29. 

The Medical Protective Co., Fort Wayne, Ind. Booth 3. 

Merck Sharp & Dohme, West Point, Pa. Booth 15. 

Melex Professional Specialties, Peoria, III. Booth 27. 

Miller Pharmacal Company, Inc., St. Louis, Mo. Booth 36. 

McNeil Laboratories, Inc., Fort Washington, Pa. Booth 37. 

The National Drug Company, Philadelphia, Pa. Booth 18. 

Organon, Inc., West Orange, N. J. Booth 24. 

Parke, Davis & Company, Detroit, Mich. Booth 34. 

Pepsi-Cola Bottlers of St. Louis, St. Louis, Mo. Booth 26. 

Pfizer Laboratories, New York, N. Y. Booth 46. 

Professional Management Midwest, Kansas City, Mo. Booth 5. 

Roche Laboratories, Nutley, N. J. Booth 31. 

William H. Rorer, Inc., Fort Washington, Pa. Booth 44. 

St. Louis Blue Shield, St. Louis, Mo. Booth 4. 

St. Louis Flying Service, Inc., St. Louis, Mo. Booth 12. 

Sanborn Company, Waltham, Mass. Booth 35. 

Sandoz Pharmaceuticals, Hanover, N. J. Booth 13. 

W. B. Saunders Company, Philadelphia, Pa. Booth 11. 

G. D. Searle & Co., Chicago, III. Booth 22. 

Smith Kline & French Laboratories, Philadelphia, Pa. Booth 32. 

E. R. Squibb & Sons, New York, N. Y. Booth 14. 

The Stuart Co., Pasadena, Calif. Booth 1. 

The Upjohn Company, Kalamazoo, Mich. Booth 40. 

U. S. Vitamin & Pharmaceutical Corp., New York, N. Y. Booth 30. 
Wallace Laboratories, Cranbury, N. J. Booth 17. 

Warner-Chilcott Laboratories, Morris Plains, N. J. Booth 19. 
Warren-Teed Pharmaceuticals, Inc., Columbus, Ohio. Booth 10. 
Westwood Pharmaceuticals, Buffalo, N. Y. Booth 21. 


March 11, 1964 


9:00 a.m. 
9:45 a.m. 

10:00 a.m. 
10:30 a.m. 

11:30 a.m. 


Biochemical Changes After Death, George E. Gantner, M.D., Di- 
rector of Laboratories, Firmin Desloge Hospital, St. Louis. 

Freezing Point Osmometry, Mary Jean Rutherford, B.S., M.T. 
(ASCP), Laboratory Supervisor, Firmin Desloge Hospital, 
St. Louis. 

Coffee Break. View Exhibits. 

Evaluation of Enzyme Techniques Used in Clinical Laboratories, 
Sam Frankel, Ph.D., Director, Division of Biochemistry, Jew- 
ish Hospital, St. Louis. 

Procedure Management in Clinical Enzyme Chemistry, Lawrence 
C. Whetzel, B.S., Supervisor, Chemistry Laboratory, Dade 
Reagents, Inc., Miami. 


County Society News 


FIRST DISTRICT 

JOSEPH L. FISHER, ST. JOSEPH, COUNCILOR 
Buchanan County Medical Society 

Sixty-six physicians attended the January 8 
meeting of the Buchanan County Medical Society 
in the Empire Room of Hotel Robidoux. A meet- 
ing and scientific program followed 6:30 dinner. 
Dr. William B. Rost, president, presided. The 
speaker was introduced by Dr. F. Gregg Thomp- 
son, III. 

The speaker was Dr. Leslie Rudolf, Associate 
Professor of Surgery at the University of Virginia, 
who spoke on “Organ Transplant.” The number 
of successful organ transplants remains small, the 
audience was informed, though progress is being 
made. Many great problems still face the sur- 
geons who attempt organ transplant, including 
the resistance of the body to “foreign” trans- 
plants; the vulnerability of the recipient to dis- 
ease because of the necessity of using medicines 
to reduce the activity of antibodies also reduce 
resistance to disease; tremendous problems of 
securing the use of organs suitable for trans- 
plant. Even so transplants are being made with 
slow but steady increasing success. The program 
was sponsored by the Phillips Roxane Company. 

Irwin Rosenthal, M.D., Secretary 


nance a Hospitality Room in St. Louis at the 
state meeting was passed. It was agreed that if 
children other than those of members took part 
in the proposed Children’s Day Program in 
March, the social hour would be dispensed with 
for that meeting. 

New members Albert Shiffet, M.D., of Wheel- 
ing and M. L. Gentry, M.D., of Chillicothe, were 
welcomed into the Society. Guests present were: 
Robert Forsyth, M.D., Kansas City 7 ; Dr. Gisela 
Betz, Munich, Germany; Mrs. Alma Kincaid, Los 
Angeles, Calif.; Mrs. Oliver Duffy, Trenton and 
representatives of Squibb and Lederle. 

Jack Vinyard, M.D., Secretary 


SECOND DISTRICT 

HARRY L. GREEN, HANNIBAL, COUNCILOR 

Chariton-Macon-Monroe-Randolph 
County Medical Society 

Kenneth C. Hollweg, M.D., Kansas City 7 , presi- 
dent of the Missouri State Medical Association, 
spoke before the Chariton-Macon-Monroe-Ran- 
dolph County Medical Society at its regular 
monthly dinner meeting Thursday night, January 
9, at the Woodland Hospital in Moberly. Dr. 
Hollweg spoke on the organizational setup of 


Grand River Medical Society 

Forty-two members and guests were present at 
the combined meeting with the Woman’s Aux- 
iliary which convened at 6:30 p.m. at the Strand 
Hotel in Chillicothe on Thursday night, January 
9. Following a social hour and dinner the ladies 
held a separate, informative program on “A Dis- 
play and Discussion of Antiques” by Mrs. Oliver 
Duffy of Trenton. 

Robert Forsyth, M.D., neurosurgeon of Kansas 
City, spoke to the doctors on, “Signs and Symp- 
toms of Central Nervous System Diesease and 
Injury.” Important subdivisions of the subject 
were head injury, convulsions, disuse of the ex- 
tremities and pain. Additional useful information 
was added during the question and answer 
period. 

Delegates and alternates to the March meeting 
of the MSMA were elected. All doctors and wives 
of the First Councilor District are to be invited 
to the June meeting if plans to obtain a legislator 
as speaker are successful. A motion by Dr. Don- 
ald Dowell to assess each member $10.00 to fi- 



Drs. J. Will Fleming, Hollweg, T. S. Fleming, Mrs. 
Hollweg and Dr. Baker were seated at the head table. 


the MSMA, discussing the county medical so- 
cieties and their function, the committee struc- 
ture, and their functions, of the State Association, 
and briefly built up in his discussion to the AMA. 

A business session of the Society followed Dr. 


218 


Volume 61 
Number 3 


ORGANIZATION ACTIVITIES 


219 



Dr. Barnett discussed the oral polio vaccine program. 


Hollweg’s interesting presentation. The Sabin 
Oral Polio program to begin on Sunday, Febru- 
ary 9, was discussed by the various county chair- 
men, namely: W. D. Chute, M.D., of Randolph; 
T. L. Harms, M.D., of Chariton; James Campbell, 
M.D., of Macon, and F. A. Barnett, M.D., of 
Monroe. The chairmen felt that the project would 
be well handled in their respective counties on 
the February 9 date. The two additional dates 
for the giving of the vaccine have been scheduled 
for March 15 and April 19 making a total of three 
feedings. In addition to Dr. Hollweg other guests 
present were: Mrs. Hollweg and Mr. Ray Mc- 
Intyre, Field Secretary of the MSMA. The mem- 
bers present were: Drs. D. E. Eggleston and J. E. 
Campbell, Macon County; Dr. F. L. Harms, 
Chariton County; Dr. F. A. Barnett, Monroe 
County; Drs. Josephine Baker, A. P. Rowlette, 
J. Will Fleming Jr., Thomas S. Fleming, W. D. 
Chute, C. C. Cohrs, L. E. Huber, Robert Hasson, 
P. V. Dreyer and S. R. Szymanski, Randolph 
County. 

J. Will Fleming Jr., M.D., Secretary 


FOURTH DISTRICT 

PAUL R. WHITENER, ST. LOUIS, COUNCILOR 

Lincoln-St. Charles County Medical Society 

A dinner meeting of the Lincoln-St. Charles 
County Medical Society was held at the Southern 
Air in Wentzville on Tuesday evening, January 7 
28. A social hour preceded dinner and the pro- 
gram. William Shieber, M.D., surgeon of St. 
Louis, spoke to the group on “Implications of the 
Lymphatic System in Clinical Practice.” 

His talk was well illustrated with slides. A 
question and answer period following the formal 
presentation brought forth additional interesting 


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220 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
March, 1964 


points relating to this particular subject. Twenty- 
one physicians were present to profit from this 
meeting. In addition to Dr. Shieber, other guests 
were Dr. Paul Whitener, St. Louis County, Coun- 
cilor of the Fourth District of the MSMA, and 
Mr. Ray McIntyre, Field Secretary of the MSMA. 

During the business part of the meeting Dr. 
Whitener spoke briefly on matters to come before 
the House of Delegates at the coming state meet- 
ing. Some time was given to discussion of the 
Missouri State Medical Foundation, its objectives 
and present status. Dr. R. E. Hammes of St. 
Charles, General Chairman for the oral polio 
vaccine program for Lincoln and St. Charles 
Counties, discussed in general the outline for this 
program which will be staged on Sunday, March 
15 and again on Sunday, May 17. The trivalent 
polio vaccine is to be offered these two days to 
the general public in the two counties. Further 
details of the program will be worked out and 
will be made known in the near future. 

R. J. Fleming, M.D., Secretary 


SIXTH DISTRICT 

O. B. BARGER, HARRISONVILLE, COUNCILOR 

Henry, Johnson, Pettis, Saline, Lafayette- 
Ray County Medical Societies 

A joint dinner meeting of the Henry, Johnson, 
Pettis, Saline, Lafayette-Ray and adjacent county 
medical societies and the doctors’ wives was held 



More than 60 doctors, wives and guests attended the 
meeting. 


at the Pacific Cafe in Sedalia on Wednesday 
night, January 15. More than 60 people were 
present to enjoy an evening of fellowship, good 
food and excellent programs. 

Following the social hour and dinner, the 



Drs. Stauffacher and Lewis, Lt. Col. Kloess and Dr. 
Hopkins got together at the close of the meeting. 


ladies were excused to hold a separate meeting 
where they were treated to a special program. 

The scientific program for the doctors was 
given by J. Eugene Lewis Jr., M.D., St. Louis, 
associate professor of clinical surgery, St. Louis 
University Medical School and Chief, Surgical 
Section, Cardinal Glennon Memorial Hospital for 
Children. Dr. Lewis spoke on “Diagnosis and 
Management of Surgical Problems in the New- 
born.’’ His was an interesting and informative 
presentation and stimulated considerable general 
discussion following his formal talk. A number 
of doctors and their wives from the Whiteman 
Air Force Base were present and most welcome. 

At the close of the evening session, Lt. Col. 
Edward J. Kloess, Commander of the 805th Med- 
ical Group at the Whiteman Air Force Base, in- 
vited the group to hold their usual May meeting 
at the Air Force Base on whatever Wednesday 
night in that month seemed most suitable. The 
invitation was unanimously accepted and the 
specific date of the meeting at the base will be 
determined in the near future. 

Elliott M. Braverman, M.D., Secretary 
Pettis County Medical Society 

West Central Missouri Medical Society 

The January meeting of the West Central Mis- 
souri Medical Society and the doctors’ wives was 
held at the Wagon Wheel Restaurant in Harrison- 
ville on Thursday evening, January 9. The even- 
ing festivities began with a social hour at 6:30 
p.m. followed by dinner and then the scientific 
program. 

David R. Weakley, M.D., dermatologist of 
Kansas City, associate professor of dermatology 
at Kansas University Medical School, spoke to 
the group on “The Medical Management of Skin 



Volume 61 
Number 3 


ORGANIZATION ACTIVITIES 


221 


Problems in General Practice— With Slide Illus- 
trations. This was an interesting and practical 
presentation and the Society is indebted to Dr. 
Weakley for this program. 

Roy Pearse, M.D., Secretary 

Lafayette-Ray County Medical Society 

The monthly meeting of the Lafayette-Ray 
County Medical Society was held at Maib’s Cafe 
in Lexington on January 14. The social hour was 
followed by the dinner. A short business meeting 
was held, presided over by President Wilbur 
Fulkerson, M.D., and a rather lively discussion 
ensued as to methods of increasing attendance 
at each meeting. 

A motion was made and passed that a program 
chairman be appointed to be responsible for a 
monthly program, and that he also invite other 
area physicians to each meeting. Drs. George 
DeVault and Charles Riley were appointed to 
the program committee. 

No further business ensued, and the meeting 
adjourned. 

W. C. LaHue, M.D., Secretary 


EIGHTH DISTRICT 

DOYLE C. MCCRAW, BOLIVAR, COUNCILOR 
Ozarks Medical Society 

The January meeting of the Ozarks Medical 
Society was held at the Lakeland Restaurant in 
Monett. The scientific program was presented by 
Lewis Ferguson, M.D., surgeon of Joplin, on the 
subject, “Intestinal Obstruction/’ 

At the Society’s meeting in December, held at 
Mount Vernon, officers for 1964 were elected as 
follows: Alan Bailey, M.D., Mount Vernon, pres- 
ident; William Hamilton, M.D., Aurora, vice 
president, and Paul B. Anderson, Neosho, secre- 
tary-treasurer. Also at the December meeting, 
Dr. L. A. Marty of Pierce City was voted an hon- 
orary member of the Society and Dr. Wilbur 
McDabbs of Neosho was voted a new active 
member. 

Paul B. Anderson, M.D., Secretary 


NINTH DISTRICT 

E. A. STRICKER, ST. JAMES, COUNCILOR 

Mid-Missouri County Medical Society 

The Mid-Missouri Medical Society and the 
doctors’ wives held a dinner meeting at the Shep- 



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222 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
March, 1964 


herd of the Hills Motel Restaurant in Lebanon 
on Thursday night, January 23. 

Following an enjoyable social hour and dinner, 
those present were privileged to hear a most in- 
teresting and informative discussion on “The 
Practice of Medicine and Its Relation to the Mis- 
souri Division of Health,” by H. M. Hardwicke, 
M.D., Jefferson City, Acting Director, Missouri 
Division of Health. 

M. K. Underwood, M.D., Secretary 


TENTH DISTRICT 

W. D. ENGLISH, CARDWELL, COUNCILOR 
Butler-Ripley- Wayne County Medical Society 

A dinner meeting of the Butler-Ripley- Wayne 
County Medical Society was held at the Hickory 
House in Poplar Bluff on Wednesday evening, 
January 22. The scientific program was presented 
by Mitchell V. Malinoski, M.D., Veterans Hos- 
pital, Poplar Bluff, who spoke on “Histamine 
Cephalalgia.” 

W. D. Robertson, M.D., Secretary 

Mineral Area County Medical Society 

A meeting of the Mineral Area Medical Society 
was held at the State Hospital in Farmington 
January 23. The meeting opened with a presen- 
tation on “Tests and Treatment for Pancreatic 
Disease” by William A. Knight Jr., M.D., of St. 
Louis University. 

Members attending included: Drs. C. H. Ap- 
pelbury, Ben Bull, T. R. Burcham, Jack Foster, 
Emmett Hoctor, Robert Huckstep, C. E. Mich- 
aelis, Van W. Taylor, Jack Mullen, C. E. Carle- 
ton, C. W. Chastain, Paul Dennis, Marvin A. 
Grossman, Marvin Haw, Alvin Karraker, William 
Patton and G. L. Watkins. 

Following the reading of the minutes the 
present status of operation Hometown was dis- 
cussed. Dr. Bull pointed out that Representative 
Ichord had polled the people of his, the eighth, 
congressional district and found that some 60 
per cent of the people polled opposed King-An- 
derson Bill, whereas some 30 per cent were in 
favor of it. Discussion was then had concerning 
the advantages of non-medical people contacting 
Congressman Jones and Congressman Ichord, 
emphasizing the disadvantages of the King-An- 
derson Bill. 

Discussion of the drug list available through 
the State Welfare Department for dispensing to 
welfare patients was then held and it was felt 


that the selection was poor and that the avail- 
ability of the list of drugs was worse. Several 
doctors related that their patients had found it 
impossible to obtain the particular drug from the 
pharmacies which were supposed to be partici- 
pating in the program. 

The decision to disaffiliate Ste. Genevieve 
County from the Mineral Area Medical Society 
and for it to affiliate with Perry Count} 7 was re- 
viewed by the membership and no opposition 
was voiced. Correspondence from the AMA and 
a variety of other organizations was reviewed 
and it was felt that no further action was needed 
at this time. 

Delegates to the State Medical Association con- 
vention were named as follows: For Madison 
County, M. A. Grossman; for Iron County, Wil- 
liam Patton; for Washington County, George 
Cresswell, and for St. Francois County, Robert 
A. Hickstep with Homer Appleberry as alternate. 

Discussion of the forthcoming oral polio im- 
munization drive in St. Francois County brought 
out that most members favor the use of the 
trivalent vaccine, if this is found to be economi- 
cally feasible in the area. There was, however, no 
opposition to the use of the monovalent. The 
group reiterated their support for the program. 
It was thought that it should be the responsibility 
of the local program sponsors in each community 
to arrange their medical coverage. 

The annual election of officers was then held. 
George A. Oliver was nominated and elected 
unanimously for president. C. E. Michaelis was 
nominated and elected unanimously for vice 
president and C. W. Chastain continues his two 
year term as treasurer and secretary. 

C. W. Chastain, M.D., Secretary 

Perry-Ste. Genevieve County Medical Society 

A dinner meeting of the new Perry-Ste. Gene- 
vieve County Medical Society, at which the 
Charter from the MSMA was presented, was 
held at the Ste. Genevieve Hotel on Thursday 
night, January 23. This was a historic occasion in- 
asmuch as all 10 active charter members of the 
new Society were present. The attendance of the 
doctors’ wives added to the importance of the 
occasion. 

The evening festivities began with an enjoy- 
able social hour followed by an excellent dinner 
and then the ceremonies suitable to the occasion. 
O. A. Carron, M.D., Perryville, president, pre- 
sided. In addition to the doctors’ wives other 
guests included W. D. English, M.D., Councilor 
of the 10th District of the MSMA from Kennett, 



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phenacetin, and 32 mg. caffeine. 


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224 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
March, 1964 



Dr. Carron received the new charter from Dr. English. 


Mr. and Mrs. T. R. O’Brien and Mr. and Mrs. 
Ray McIntyre of St. Louis. 

Following dinner the president introduced the 
guests and then called on Dr. English to speak 
to the group. Dr. English complimented the mem- 
bers of the new Society in their coming together 
into one medical group so that they might be 



Charter members posed with Councilor English. 


more effective in the area in promoting the 
health of the people and the betterment of the 
medical profession. He pointed out that the size 
of the Society was not the important thing, but 
the interest and willingness to work together for 
the good of all. After his brief remarks, Dr. Eng- 


lish presented the new charter for the Perry-Ste. 
Genevieve County Medical Society issued in be- 
half of the MSMA to Dr. Carron. Mr. O’Brien 
and Mr. McIntyre were introduced and both 
spoke briefly. 

The charter for the Society was dated as of 
December 17, 1963, and signed by John I. Mat- 
thews, M.D., Secretary and Kenneth C. Hollweg, 
M.D., President, respectively of the MSMA. The 
date of December 17 was the organizational 
meeting of the new Society and the termination 
of the old Perry County Society. Approval for 
hyphenation of the two counties was given by 
the Council of the MSMA at its meeting on the 
weekend of December 7 and 8, 1963. The activ e 



Dinner preceded the ceremonies. 


charter members of the Perry-Ste. Genevieve 
Society are: Drs. Oscar A. Carron, Perryville; 
Gerard H. DeGenova, Ste. Genevieve; James 
Fairchild, Perryville; Lawrence W. Feltz, Perry- 
ville; Theodore Fischer, Altenburg; Richard C. 
Lanning, Ste. Genevieve; Stanley G. Legner, 
Perryville; Joseph F. Lutkewitte, Ste. Genevieve; 
Alfred E. McDermott, Perryville, and William 
Utterman, Perryville. 

The officers are O. A. Carron, M.D., Perry- 
ville, president; R. C. Lanning, M.D., Ste. Gene- 
vieve, vice president; and Joseph F. Lutkewitte, 
Ste. Genevieve, secretary-treasurer. 

Joseph F. Lutkewutte, M.D., Secretary 


ADVERTISEMENTS 


225 


Post- Graduate Program 

“THE PHYSIOLOGICAL BASIS FOH DIAGNOSIS 
AND TREATMENT OF DISEASE” 

Co-Sponsors 

Department of Internal Medicine 
St. Louis University School of Medicine 
and 

Missouri State Medical Association 

St. Louis University Hospitals 
Firmin Desloge Hospital 
Miller Hall 

Wednesday, March 11, 1964 

Morning Session— G oronwy O. Broun Sr., M.D., Dean, St. Louis University 
School of Medicine— Presiding. 

10:00 New Concepts of Parathyroid Function in Clinical Disease 

Thomas F. Frawley, M.D., Professor of Medicine; Director, Department 
of Internal Medicine 

10:30 The Basis of Therapy of Diabetes Mellitus 

Henry E. Oppenheimer, M.D., Associate Professor of Clinical Medicine 
11:00 Recent Trends in the Study of Iron Metabolism 

Neil I. Gallagher, M.D., Assistant Professor of Medicine 
11:30 Newer Concepts of the Disorders of Iron Metabolism 

Goronwy O. Broun Jr., M.D., Assistant Professor of Medicine 
12:00 General Discussion 

12:30 Lunch— Firmin Desloge Hospital Cafeteria 

Afternoon Session — Ralph A. Kinsella Sr., M.D., Professor Emeritus, 
Department of Internal Medicine— Presiding. 

1:30 Pathophysiology and Therapy in Chronic Pulmonary Insufficiency 
Herbert C. Sweet, M.D., Professor of Clinical Medicine 
2:00 Evaluation of the Hypertensive Patient 

James G. Janney Jr., M.D., Associate Professor of Clinical Medicine 
2:30 Antibiotics and Host Response in the Management of Infectious Disease 
R. William Burmeister, M.D., Instructor in Internal Medicine 
3:00 The Malabsorption Syndrome 

Guy E. Van Goidsenhoven, M.D., Assistant Professor of Medicine 
3:30 General Discussion 

Registration Fee — $10.00, includes lunch 

Send Inquiries to: W. A. Knight Jr., M.D. 

Department of Internal Medicine 
St. Louis University School of Medicine 
1325 South Grand Blvd. 

St. Louis 4, Missouri 


New Members 


Rea Beck, M.D., 4316 B. McAdoo Court, 
Mehlville, has become a member of St. Louis 
County Medical Society. Dr. Beck is a native of 
Quincy, 111., received her preliminary education 
at Washington University, and her M.D. degree 
at Missouri University in 1961. She specializes in 
chest diseases. 

Charles P. Blunt, M.D., 60 Plaza Square, St. 
Louis, has become a member of St. Louis County 
Medical Society. Dr. Blunt is a native of Lynch- 
burg, Va., received his preliminary education at 
Lynchburg College, and his M.D. degree at 
Virginia Medical College in 1943. He specializes 
in surgery. 

Katherine S. Brown, M.D., 1304 Vine St., Ful- 
ton, has become a member of Callaway County 
Medical Society. Dr. Brown is a native of Gordo, 
Ala., received her preliminary education at Hunt- 
ingdon College, and her M.D. degree at Wash- 
ington University in 1934. She specializes in 
anesthesiology. 

George S. Devins, M.D., 4949 Rockhill Road, 
Kansas City, has become a member of Jackson 
County Medical Society. Dr. Devins is a native 
of Kansas City, received his preliminary educa- 
tion at Rockhurst College, and his M.D. degree 
at the University of Kansas in 1962. He special- 
izes in internal medicine. 

Marvin F. Goldstein, M.D., 751 E. 63rd St., 
Kansas City, has become a member of Jackson 
County Medical Society. Dr. Goldstein is a na- 
tive of Kansas City, received his preliminary 
education at the University of Missouri, and his 
M.D. degree at the University of Missouri in 
1959. He specializes in ophthalmology. 

Joe S. Gunter, M.D., 902 Edmond St., St. Jo- 
seph, has become a member of Buchanan County 
Medical Society. Dr. Gunter is a native of Dal- 
las, Tex., received his preliminary education at 
Southern Methodist University, and his M.D. 
degree at Southwest University in 1951. He spe- 
cializes in urology. 

Charles E. H’Doubler, M.D., Professional 
Bldg., Springfield, has become a member of 
Greene County Medical Society. Dr. H’Doubler 
is a native of Springfield, Mo., received his pre- 
liminary education at Arkansas University, and 
his M.D. degree at Tulane University in 1957. 
He specializes in surgery. 

Joseph W. Hoard, M.D., 129 E. Kirkham 
Road, Webster Groves, has become a member 
of St. Louis County Medical Society. Dr. Hoard 


is a native of St. Louis, received his preliminary 
education at Lincoln University, and his M.D. 
degree at Meharry Medical College in 1952. 
He specializes in internal medicine. 

Sumner Holtz, M.D., 950 Francis Place, St. 
Louis, has become a member of St. Louis County 
Medical Society. Dr. Holtz is a native of Haver- 
hill, Mass., received his preliminary education at 
Tufts College, and his M.D. degree at St. Louis 
University in 1948. He specializes in radiology. 

Johannes W. Hulstra, M.D., 1211 S. Glenstone 
St., Springfield, has become a member of Green 
County Medical Society. Dr. Hulstra is a native 
of Apeldoorn, Holland, received his preliminary 
education at Gymn. Apeldoorn, Holland, and his 
M.D. degree at Rijks-Universiteit te Leiden Fac- 
ulteit der Geneeskunke, Netherlands, in 1954. He 
specializes in psychiatry. 

Alan G. Johnson, M.D., 57 Chafford Woods, 
St. Louis, has become a member of St. Louis 
County Medical Society. Dr. Johnson is a native 
of Boone, Iowa, received his preliminary educa- 
tion at Oberlin College, and his M.D. degree at 
Washington University in 1956. He specializes in 
psychiatry. 

Carlyn M. Kline, M.D., 17 Stonecrest, St. Jo- 
seph, has become a member of Buchanan County 
Medical Society. Dr. Kline is a native of Milwau- 
kee, Wis., received his preliminary education at 
the University of Wisconsin, and his M.D. degree 
at the University of Wisconsin in 1956. He spe- 
cializes in general practice. 

Albert G. Lewis, M.D., Platte Medical Clinic, 
Platte City, has become a member of Platte 
County Medical Society. Dr. Lewis is a native of 
Midway, Ala., received his preliminary education 
at the University of Alabama, and his M.D. de- 
gree at Jefferson Medical College in 1945. He 
specializes in internal medicine. 

Arthur B. Lissner, M.D., 6944 Chippewa St., 
St. Louis, has become a member of St. Louis 
County Medical Society. Dr. Lissner is a native 
of New York, N. Y., received his preliminary 
education at the University of Omaha, and his 
M.D. degree at Jefferson Medical College in 
1955. He specializes in plastic surgery. 

Wallace S. Marsh, M.D., 8630 N. Oak St., 
Kansas City, has become a member of Clay 
County Medical Society. Dr. Marsh is a native of 
Minneapolis, Minn., received his preliminary 
education at the University of Omaha, and has 


Volume 61 
Number 3 


ORGANIZATION ACTIVITIES 


227 


M.D. degree at the University of Nebraska in 
1962. He specializes in general practice. 

F. James Marston Jr., M.D., 902 Edmond St., 
St. Joseph, has become a member of Buchanan 
County Medical Society. Dr. Marston is a native 
of Boonville, Mo., received his preliminary edu- 
cation at the University of Missouri, and his 
M.D. degree at the University of Louisville in 
1955. He specializes in obstetrics and gynecol- 
ogy- 

Richard B. Oglesby, M.D., 950 Francis Place, 
St. Louis, has become a member of St. Louis 
County Medical Society, Dr. Oglesby is a native 
of Atlanta, Ga., received his preliminary educa- 
tion at Washington University, and his M.D. 
degree at Washington University in 1958. He 
specializes in ophthalmology. 

Allen G. Parleman, M.D., 701 E. 63rd St., 
Kansas City, has become a member of Jackson 
County 7 Medical Society. Dr. Parleman is a na- 
tive of Kansas City, received his preliminary ed- 
ucation at Washington University 7 , and his M.D. 
degree at Washington University in 1959. He 
specializes in ophthalmology. 

R. W. Penick, M.D., 12501 Maret Drive, St. 
Louis, has become a member of St. Louis County 
Medical Society 7 . Dr. Penick is a native of Mad- 
ison, Ga., received his preliminary education at 
Emory University 7 , and his M.D. degree at the 
University of Georgia in 1949. He specializes in 
pediatrics. 

E. Robert Schultz, M.D., 3252 January St., St. 
Louis, has become a member of St. Louis County 
Medical Society. Dr. Schultz is a native of Cape 
Girardeau, Mo., received his preliminary educa- 
tion at S. E. Missouri State College, and his 
M.D. degree at Washington University 7 in 1953. 
He specializes in neurology and psychiatry. 

Bemd Silver, M.D., 1332 Grand Dr., St. Louis, 
has become a member of St. Louis County Med- 
ical Society. Dr. Silver is a native of Essen, Ger- 
many, received his preliminary education at the 
University of Louisville, and his M.D. degree at 
the University 7 of Louisville in 1956. He special- 
izes in ophthalmology. 

C. Franklin Smith, M.D., Rt. 3, Willow 
Springs, has become a member of South Central 
County Medical Society. Dr. Smith is a native of 
Fremont, Mo., received his preliminary education 
at the University of Missouri, and his M.D. de- 
gree at the University 7 of Missouri in 1960. He 
specializes in general practice. 

Jim R. Waterfield, M.D., 1211 S. Glenstone St., 
Springfield, has become a member of Greene 
County Medical Society. Dr. Waterfield is a na- 
tive of Moberly, Mo., received his preliminary 


education at the University of Missouri, and his 
M.D. degree at Washington University in 1956. 
He specializes in internal medicine. 

Newton B. White, M.D., 600 S. Kingshighway 
Blvd., St. Louis, has become a member of St. 
Louis Medical Society. Dr. White is a native of 
Chicago, 111., received his preliminary education 
at Miami University, and his M.D. degree at the 
University of Cincinnati in 1957. He specializes 
in orthopedics. 

S. Dwight Woods, M.D., 4320 Wornall Road, 
Kansas City, has become a member of Jackson 
County Medical Society. Dr. Woods is a native 
of Tyro, Kan., received his preliminary education 
at the University of Kansas, and his M.D. degree 
at the University of Kansas in 1955. He special- 
izes in surgery. 


DEATHS 

Northup, Glenn R., M.D., St. Louis, a gradu- 
ate of Hahnemann Medical College, 1923; mem- 
ber of St. Louis Medical Society; aged 72; died 
January 7, 1964. 

Barker, Jesse W., M.D., St. Louis, a graduate 
of the University of Kansas City, 1900; member 
of St. Louis Medical Society; aged 92; died Jan- 
uary 8, 1964. 

Richardson, Reginald G., M.D., Jefferson City 7 , 
a graduate of Howard University, 1915; member 
of Cole County Medical Society; aged 84; died 
January 7 8, 1964. 

Seeley, J. Bradford, M.D., Independence, a 
graduate of the University of Michigan, 1916; 
member of Jackson County Medical Society 7 ; 
aged 72; died January 10, 1964. 

Munsch, Augustus P., M.D., St. Louis, a grad- 
uate of Jefferson College, 1903; member of St. 
Louis Medical Societv; aged 85; died Januarv 13, 
1964. 

Burford, E. Humber, M.D., Ladue, a graduate 
of Washington University 7 , 1934; member of St. 
Louis Medical Societv 7 ; aged 55; died January 19, 
1964. 

Dickson, Frank D., M.D., Kansas City, a grad- 
uate of the University 7 of Pennsylvania, 1905; 
member of Jackson County 7 Medical Society 7 ; 
aged 82; died January 7 19, 1964. 

Clark, J. F. W., M.D., University 7 City 7 , a 
graduate of Harvard University, 1920; member 
of St. Louis Medical Society 7 ; aged 70; died Jan- 
uary 25, 1964. 

Gibbons, Edward H., M.D., St. Louis, a grad- 
uate of the University of Buffalo, 1926; member 
of St. Louis Medical Societv 7 ; aged 66; died Feb- 
ruary 1, 1964. 


228 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
March, 1964 


FINANCIAL STATEMENT FOR 
THE YEAR 1963 

LENNERTSON & COMPANY 

CERTIFIED public accountants 
214 South Bemiston Avenue 


ST. LOUIS, MISSOURI 63105 
January 28, 1964 

Missouri State Medical Association, 

634 North Grand Blvd., 

St. Louis, Mo. 

Gentlemen: 


An examination has been made of the accounts of the Missouri 
State Medical Association, a non-profit Missouri corporation, for 
the year 1963 and a report thereon is presented together with 
the following exhibits : 


Exhibit A 
Exhibit B 
Exhibit C-l 
Exhibit C-2 
Exhibit D 


Balance Sheet 
Income Statement 
Statement of Investments 

Statement of Committee and Meeting Expense 
Dues Receivable and Membership by Societies 


It should be noted that members’ dues are taken into income on 
the cash basis whereas the other accounts are maintained on the 
accrual basis. Items paid in advance are shown as prepaid and 
carried forward to the year to which they apply. 


Scope of Examination 

The Balance Sheet at December 31, 1963 and the Income 
Statements for the year then ended were reviewed. Examina- 
tions or tests were made of the accounting records, in the manner 
and to the extent deemed appropriate, without making a detailed 
audit of the transactions. 

Recorded cash receipts for the year were traced in total into 
the bank as deposits and disbursements for the period were 
substantiated by an inspection of paid checks, purchase invoices 
and other data on file. 


Income Statement 

The financial result of the activities of the Association for 
the year 1963 was an excess of income over expenses of $8,370.41 
as set forth in Exhibit B. Exhibit C-2 presents a summary of 
committee and meeting expenses for the year. 

Selective tests were made of the income and expense accounts 
for the period. It was noted that space in The Journal was 
contributed to the United States Treasury Department for bond 
advertising, to members and widows of members for small classi- 
fied ads and to the Missouri State Medical Foundation. 


Balance Sheet 

The financial position of the Association at December 31, 
1963 is presented in Exhibit A. Comments on the larger Balance 
Sheet accounts follow: 

Cash in banks, as shown by the books, was reconciled with 
the regular monthly bank statements and confirmations received 
from the depositaries. The petty cash fund was verified by 
physical count. 

Investments with a cost of $112,335.30 were confirmed by a 
statement from the custodian. Mercantile Trust Company. In- 
vestment income for the year consisted of the following : 


Interest and Discount on Bonds $3,013.48 

Dividends on Stock 983.70 

Total Investment Income $3,997.18 


Accounts Receivable of $3,943.53 represent the unpaid balance 
due from Advertisers. Of this amount $3,846.53 was due from 
the State Journal Advertising Bureau for the month of December 
1963. 

Unpaid Dues of $1,247.50, offset by a reserve account in like 
amount, represent 1963 dues of delinquent members carried at 
the request of local societies. Other delinquent members were 
dropped from membership in accordance with the by-laws. Ex- 
hibit D presents a summary of unpaid dues and membership by 
societies, as shown by the records of the Association. 

Furniture and Fixtures continue to be stated in the fixed 
amount of $1,000. Equipment purchases and repairs for the 
year in the total of $635.20 were charged to expense in lieu of 
depreciation. 

The records were carefully reviewed for liabilities at Decem- 
ber 31, 1963 and it is believed that all current liabilities of 
substantial amount are included in the Balance Sheet. The 
by-laws require the Association to furnish financial assistance, 


not to exceed $300, on each mal-practice suit. The Association 
reports no knowledge of any pending suits against members. 

Exhibitors have made advance payments of $4,811.00 for 
annual session exhibit space and these payments will be taken 
into income when earned in 1964. 

The excess of assets over liabilities in the amount of $123,- 
212.64 is shown in the Balance Sheet as a “Reserve for Future 
Activities.” 

General 

During the year, payments were made to or for the following 
sponsored organizations : 

Missouri State Medical Association Pension Trust 


Employees’ Retirement Insurance Premiums $4,055.65 

Employees’ Pension Plan Contribution 3,944.35 

Total $8,000.00 


Missouri State Medical Foundation 

Stationery, printing, insurance and audit $ 695.25 


The Missouri State Medical Association collected as a part 
of its annual dues $7.50 per active member and $3.75 per junior 
member for the Missouri State Medical Foundation. The total 
collected for the Foundation during the year 1963 was $24,333.41. 

Insurance policies were inspected and the following general 
insurance was in force at the close of the year : 


Insurance on 


Type of Coverage 


Amount 


Furniture and Fixtures 

Employees 
Lessee’s Liability 
President and Treasurer 
All Other Employees 
Automobiles of 

Executive Secretary 
Field Secretary 
Executive’s Assistant 


Fire and Extended Coverage 

(80% co-ins.) $6,500 

Workmen’s Compensation Statutory 

Bodily Injury $25,000/50,000 

Fidelity Bond $20,000 

.Fidelity Bond $5,000 

Non-ownership — 

Bodily Injury $50,000/100,000 

N on-ownershi p — 

.Property Damage $5,000 


Subject to the comments thereon, the attached statements, in 
our opinion, present fairly the financial position of the Missouri 
State Medical Association at December 31, 1963 and the financial 
results of its activities for the year then ended, in accordance 
with accepted principles of accounting applied on a basis con- 
sistent with that of the preceding year. 

Yours very truly. 

Lennertson & Company 

Certified Public Accountants. 


Exhibit A 


Missouri State Medical Association 
Balance Sheet, December 31, 1963 


Assets 

Cash 

Mercantile Trust Company (Treasurer’s 

Account) $ 10,906.98 

Mercantile-Commerce National Bank (Sec- 
retary’s Account) 118.22 

Petty Cash Fund 22.47 $ 11,04 < .6 » 


Investments at Cost (Exhibit C-l) 

U. S. Government Bonds $ 80,319.48 

Corporate Bonds 5.000.00 

Common Stocks 27,015.82 


Total (Market Value $112,832.50) . 112.335.30 

Accounts Receivable 

Advertising 5 3,943.53 

Mercantile Trust Company — Investment 

Custodian 1,139.49 5,083.02 


Dues Receivable — Exhibit D 1,24.. 50 

Furniture and Fixtures (at stated values) 1,000.00 

Advances for Travel Expenses 


$131,016.79 


Liabilities 

Accounts Payable 

Supplies and Expenses $ 616.36 

Payroll Taxes 711.81 

Medical Associations 417.48 $ 1.745.65 

Deferred Credit to Income 

Advance Payments by Exhibitors 4,811.00 

Contingent Liability to Members on Mal- 
practice Suits — none reported 

Reserve for Uncollected Dues 1,247.50 

Reserve for Future Activities 

Balance January 1, 1963 $114,842.23 

Excess of Income Over Expenses for the 

year 1963— (Exhibit B) 8,370.41 123.212.64 

$131,016.79 


Volume 61 
Number 3 


ORGANIZATION ACTIVITIES 


229 


Exhibit B 


Exhibit C-2 


Missouri State Medical Association 
Income Statement for the Year 1963 


General Journal 

Particulars Activities Publication Total 

Income 


Dues Received (includes $1.50 
per member annually for The 

Journal) 

Rentals — Annual Session Ex- 
hibit Space 

Subscriptions to The Journal 

— Nonmembers 

Advertising Space — T he Jour- 
nal 

Investments — Interest and Divi- 
dends 

Collection Fees on AMA Dues 
Rental Income — Office Space . . 

Total Income 


$132,932.59 $ 5,244.00 $138,176.59 


9,050.00 9,050.00 

248.15 248.15 

38,368.23 38,368.23 

3,997.18 3,997.18 

1,430.07 1,430.07 

540.00 540.00 


$147,949.84 $43,860.38 $191,810.22 


Statement of Committee and Meeting Expenses 
For the Year 1963 


Annual Session $14,663.95 

Council Meetings and Councilors’ Expenses 6,966.46 

Delegates to AMA 4,360.85 

Public Service 16,980.01 

Women’s Auxiliary 1,972.41 

Committees : 

Aging $475.21 

Cancer 11.64 

Civil Defense 471.09 

Infant Care 108.16 

Maternal Welfare 313.74 

Medical Education 152.63 

Mental Health 36.56 

Publication 263.98 

Redistricting 106.47 

Rural Medical Service 34.89 

Scientific and Post Graduate Work 170.23 

Venereal Disease Control 14.00 

Total 2,158.60 


$47,102.28 


Expenses 


Salary — Executive Secretary . . 

$ 10,800.00 

$ 5,400.00 $ 

16,200.00 

Office Salaries 

31,367.26 

15,683.62 

47,050.88 

The Journal — Paper, Print- 
ing, etc 


29,727.73 

29,727.73 

Cash Discount to Advertisers 


380.70 

380.70 

Commission on Journal Ad- 
vertising 


4,708.27 

4,708.27 

Postage 

2,916.48 

824.26 

3,740.74 

Committee and Meeting Ex- 
penses (Exhibit C) 

47,102.28 


47,102.28 

Custodian Fees — Investments . 

242.69 


242.69 

Directories and Clipping Service 

542.14 


542.14 

Dues and Subscriptions 

653.10 


653.10 

Employees’ Pension Plan Con- 
tributions 

8,000.00 


8,000.00 

Equipment Purchases and Re- 
pairs in lieu of Depreciation 

635.20 


635.20 

General Expense 

206.60 


206.60 

Insurance — Blue Cross 

464.76 


464.76 

Insurance — General 

344.29 


344.29 

Missouri State Medical Founda- 
tion 

695.25 


695.25 

Office Rent and Light 

4,577.15 


4,577.15 

Professional Fees 

3,452.64 


3,452.64 

Stationery, Printing and Office 
Supplies 

5,987.10 


5,987.10 

Student Awards 

225.00 


225.00 

Taxes — Payroll and Personal 
Property 

1,596.44 


1,596.44 

Telephone and Telegraph 

2,262.49 


2,262.49 

Traveling Expense — Executive 
Secretary 

1,686.92 


1,686.92 

Traveling Expense — Field Sec- 
retary 

2,504,79 


2,504.79 

Traveling Expense — Executive 
Assistant 

452.65 


452.65 

Total Expenses 

$126,715.23 $56,724.58 $183,439.81 

Excess of Income or (Expenses) $ 21,234.61 ($12,864.20) $ 

8,370.41 


Exhibit C-l 


Missouri State Medical Association 
Statement of Investments, December 31, 1963 


Description 

U. S. Treasury 2 J4% Bond 6/15/67-62 


Bonds at 

Par Value Cost 
$10,000.00 $ 10,000.00 


U. S. Treasury 2 y 2 % Bond 12/15/68-63 10,000.0( 

U. S. Treasury 2 y 2 % Bond 6/15/69-64 10,000.0( 

TJ. S. Treasury 2 l / 2 % Bond 3/15/70-65 10, 000.01 

U. S. Treasury 2 y 2 % Bond 3/15/71-66 5,500.0( 

U. S. Treasury 3^% Bond 5/16/68 10,000.01 

U. S. Treasury 4 %Bond 10/1/69 25,000.01 

Pacific Gas and Electric i]/ 2 % Bonds 6/1/90 5,000.0< 
Central and Southwest Corporation 200 shares 
Johns Manville Corporation 100 shares 
Morgan Guarantee Trust Co. of N. Y. 55 shares 
Standard Oil Co. of California 100 shares 
Union Carbide Corp. 37 shares 


10,000.00 

9,960.91 

9,901.72 

5,445.86 

9,984.44 

25,026.55 

5,000.00 

6,345.62 

5,582.34 

5,106.55 

5,045.94 

4,935.37 


Total 


$112,335.30 


Exhibit D-l 


Missouri State Medical Association 
Dues Receivable and Membership by Societies 
December 31, 1963 

MEMBERSHIP 


Societies 

'S 

© 

•S 

© 

© 


Is 

s S 


•■s 




S5Q 



4 

1 

5 


Audrain 


18 

2 

20 


Barton-Dade 

1 

7 


8 





1 

1 


Boone 

. 15 

99 

2 

116 

$50.00 


6 

69 

14 

89 

50.00 

Butler- Wayne-Ripley 

2 

34 

36 

Callaway 


16 

3 

19 

50.00 

Cape Girardeau 

5 

43 

4 

52 


Carter-Shannon 


1 


1 


Chariton-Macon-Monroe-Randolph 


21 

4 

25 



. 10 

52 

1 

63 

10.00 

Clinton 


5 


5 

Cole 

4 

39 

5 

48 


Cooper 


10 


10 


Dallas-Hickory-Polk 


6 

2 

8 



2 

15 

5 

22 



2 

27 


29 

50.00 

Grand River 

4 

41 

5 

50 

75.00 


. 21 

133 

11 

165 


Henry 


11 

1 

12 



. . 2 

5 


7 



. 58 

621 

113 

792 


Jasper 

2 

57 

5 

64 

75.00 



16 

1 

17 




12 

1 

13 


Lafayette-Ray 

4 

19 


23 

50.00 

Lewis-Clark-Scotland 


2 


2 



. 10 

19 

1 

30 


Marion-Ralls-Shelby 

4 

22 

4 

30 

50.00 



29 

1 

30 

50.00 



2 


2 


2 

26 

4 

32 

12.50 



4 


4 

Montgomery 


3 

1 

4 




4 


4 


Nodaway-Holt-Atchison-Gentry- 






Worth 


14 

2 

16 


North Central 


11 

1 

12 



2 

42 

7 

51 



1 

16 

2 

19 

100.00 

Perry-Ste. Genevieve 


10 

1 

11 


1 

24 

5 

30 


Pike 

2 

5 

3 

10 


Platte 


5 


6 


St. Louis City 

. 192 

1,016 

103 

1,311 

550.00 

St. Louis County 

. 26 

385 

43 

454 


Saline 

1 

12 

3 

16 


Semo 

1 

30 

3 

34 

50.00 

South Central 

3 

15 

2 

20 

25.00 


1 

2 

1 

4 


West Central 

4 

29 

10 

43 


Totals 

. 388 

3,108 

378 

3,874 l 

Sl.247.50* 


(A) Delinquent dues of members at December 31, 1963 carried 
at the request of local societies. 


From the 
Medical Schools 



WASHINGTON UNIVERSITY 
Salt Transport Research 

Biological research in progress at Washington 
University School of Medicine may provide a 
clue to one of man’s oldest problems— how to 
utilize sea water for fresh water purposes. Dr. 
Neal S. Bricker, director of the School’s Renal 
Division, recently became one of the first inves- 
tigators in the biological sciences to receive a 
grant from the U. S. Department of the Interior. 

Dr. Bricker, who is an associate professor of 
medicine, is investigating the process of transport 
of salt and other solutions across living mem- 
branes. His experiments are now using a model 
system with a turtle bladder for the membrane. 
The Office of Saline Waters, which awarded the 
grant, may ultimately utilize information derived 
from the project to its problems of removing salt 
from sea water for possible use in irrigation. 

In the model set-up, the turtle bladder is used 
to separate two solutions, one of which contains 
a radioisotope, usually of sodium, a common salt. 
With use of a fine measuring device, an auto- 
gamma spectrometer, the amount of the isotope 
which passes through the membrane may be 
measured. The goal of this project is to identify 
the manner in which energy is used within the 
membrane to pump the salt solution through 
the membrane. The turtle bladder model is used 
for the experiment because it provides a simpli- 
fied set-up for a complicated problem. 

Dr. Bricker and his associates know that en- 
ergy is produced in the bladder by conversion of 
the glycogen within the bladder cells. They have 
found that the bladder will synthesize energy 
for as long as 12 hours. They have also found 
that oxygen does not have to be present for this 
process to occur. In most membranes that pump 
salt, oxygen is essential. 

If the energy transforming processes can be 
identified, the information can be utilized to ex- 
tend knowledge of kidney function and other 
organs in both healthy man and in the disease 
process. “Our interest here lies in learning more 
about how living systems control their body 
fluids in relation to their environment,” Dr. 
Bricker said. “The kidney is the major organ of 


protection within the body. It is also one of the 
most inaccessible and most complicated. 

“A number of scientists are now using simple 
systems, such as our turtle bladder model, to 
obtain basic information which may be applied 
to the kidney. Dr. Bricker said that with the era 
of success in kidney transplants so near and with 
the expanding use of the artificial kidney for 
chronic disease, research on the kidney is of in- 
creasing importance. 

New Academy Head 

Dr. Fred C. Reynolds, professor of orthopedic 
surgery, has been named president-elect of the 
American Academy of Orthopaedic Surgeons. He 
will take office in January 1965 at the annual 
meeting scheduled for New York City. The 
Academy, which works for advancement in all 
phases of orthopedic surgery, is composed of 
physicians who have practiced the specialty for 
at least three years and who have been certified 
by the American Board of Orthopaedic Surgery. 
Dr. Reynolds has served for the last two years 
as president of the American Board of Ortho- 
paedic Surgery. 

Grant Visiting Professor 

Dr. Wesley Spink, professor of medicine at 
the University of Minnesota, served as the first 
Samuel Grant Visiting Professor of Medicine at 
Washington University School of Medicine in 
January. Dr. Spink is an authority on infectious 
diseases, especially brucellosis and shock reac- 
tions produced by bacterial infection. He is pres- 
ident of the American College of Physicians and 
presented the Lister Lecture in London in late 
January. 

The professorship honors the well known St. 
Louis physician and alumnus of the Medical 
School. Dr. Grant has been a member of the 
School of Medicine faculty for many years and 
has served as president of the Medical Alumni 
Association. He also served as chairman of the 
campaign which raised funds for the Spencer T. 
Olin residence hall for medical students and has 
been a member of the University’s board of di- 
rectors as alumni representative for the Medical 
School. 


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232 


MISCELLANY 


Missouri Medicine 
March, 1964 


Last year the student health service on the 
main campus of Washington University was 
named for him. The fund for the visiting profes- 
sorship was initiated by a gift of the late Mr. 
Jack Poliak of St. Louis and contributed to by 
other former patients. 

Recent Programs 

Future directions of science were discussed 
by a panel of four Washington University pro- 
fessors at the meeting of History of Science and 
Medicine Society in February. Participating in 
the discussion were George Pake, provost and 
professor of physics; Barry Commoner, professor 
of plant physiology, and Richard Rudner, pro- 
fessor of philosophy. Dr. Carl Moyer, Bixby pro- 
fessor and head of the department of surgery, 
moderated the panel. 

A colloquium on biochemical differentiation 
and regulation was held at the last meeting of 
the Washington University Medical Society. Dr. 
Florence Moog, professor of zoology, discussed 
control of enzyme activity in developing systems. 
Dr. Helen Burch, associate professor of pharma- 
cology, discussed biochemical changes in peri- 
natal rat liver, and Dr. David E. Kennell, assist- 
ant professor of microbiology, spoke on the reg- 


ulation of RNA synthesis in bacteria. The con- 
vener of the program was Dr. David H. Brown, 
professor of biological chemistry. 

Upcoming Lectures 

Dr. Harry Eagle, chairman of the department 
of cell biology at Albert Einstein College of Med- 
icine of Yeshiva University, will present the 
twelfth annual Robert J. Terry Lecture on March 
2 in Clopton Amphitheatre. He will speak on 
metabolic controls in cultured human cells. 

Studies on virus-cancer relationships will be 
discussed by Dr. Albert B. Sabin for the twelfth 
annual Seelig Lecture on March 30. Dr. Sabin is 
distinguished service professor at the University 
of Cincinnati. 

The Washington University History of Med- 
icine and Science Society will meet on March 31 
to hear discussions on medicine in other coun- 
tries. Dr. John Smith, associate professor of med- 
icine, will speak on his recent year in Colombia. 
Dr. Malcolm Peterson, assistant professor of 
medicine, will discuss Washington University’s 
participation in the CARE program in Algiers. 

Alumni Reception 

The Washington University Medical Alumni 


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In the ketoacidosis-resistant obese diabetic not amenable to diet alone, hypoglycemic DBI (phenformin HCl) appears to 
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Bibliography: 1. Williams, R. H.: Textbook of Endocrinology, Ed. 3, Saunders, Philadelphia, 1962, p. 610. 2. Gordon, E. S. : Metabolism 11:819, 
1962. 3. Grodsky, G. M. et al.: Metabolism 12:278, 1963. 4. Sadow, H. S.: Metabolism 12:333, 1963. 5. West, K. M. and Tophoj, E.: Metabolism 
10:689, 1961. 6. Yalow, R. S. and Berson, S. A.: Diabetes 9:254, 1960. 7. Weller, C. et al.: Scientific ExhiDit, A.M.A., June 1962. 8. Weller, C. 
et al.: Metabolism 11:1134, 1962. 9. Radding, R. S. et al.: Metabolism 11:404, 1962. 

U.S. VITAMIN & PHARMACEUTICAL CORPORATION SKS 



Volume 61 
Number 3 


MISCELLANY 


233 


Association will sponsor a reception for alumni 
and friends during the annual meeting of the 
Missouri Medical Association in St. Louis. The 
reception, which will be held from 6:00 to 7:30 
p.m., Tuesday, March 10, in the Coach Room of 
the Chase-Park Plaza Hotel, will honor Dr. Leon- 
ard T. Furlow, associate professor of clinical neu- 
rological surgery at the Medical School. Dr. Fur- 
low will be installed as president of the State 
Medical Association at the banquet following the 
reception. 

UNIVERSITY OF MISSOURI 
Missouri Professors Publish Books 

A comprehensive review of the entire field of 
germfree research, a new tool in the biological 
sciences, is presented in a new book by Dr. 
Thomas D. Luckey, professor and chairman of 
the Department of Biochemistry at the University 
of Missouri Medical Center. Dr. Luckey has been 
working with germfree animals for more than 20 
years, and has received international recognition 
in that field. 

Dr. Frank B. Engley Jr., professor and chair- 
man of the Department of Microbiology at the 
University of Missouri Medical Center, is the 


author of a concise, comprehensive 338 page 
“Pocket Reference Guide to Medical Micro- 
biology” which has been recently published. The 
manual is based on reference material collected 
by Dr. Engley over a period of 14 years for use 
by his students and others in the field of micro- 
biology. 

Appointments 

Marion Spencer DeWeese, M.D., Ann Arbor, 
Mich., has been appointed professor of surgery 
and chairman of the Department of Surgery at 
the University of Missouri Medical Center. Dr. 
DeWeese fills the vacancy created January 1 by 
Dr. John J. Modlin, who will resume private 
practice. Dr. Modlin remains on the Medical 
Center staff as a clinical consultant. Until June 1, 
when Dr. DeWeese’s appointment becomes ef- 
fective, John Franklin Patton, M.D., associate 
professor of surgery (urology) will be acting 
chairman of the department. Dr. Patton has re- 
cently retired as Colonel in the United States 
Army Medical Corps, Chief of the Department of 
Surgery at Walter Reed General Hospital in 
Washington, D. C., and consultant in urology to 
the Surgeon General of the Army. Dr. DeWeese 



Missouri Medicine 
March, 1964 



he’ll like the way 
it tastes 

;: By liquefying secretions in the 
respiratory tree, Cheracol makes it easier 
for the patient to cough — in accord 
with the physiologic defense mechanism. 



I Upjohn 


is at present associate professor of surgery at the 
University of Michigan. 

Dr. Frank B. Engley Jr., professor and chairman 
of the Department of Microbiology, has been ap- 
pointed to the editorial board of the Journal of 
Bacteriology, the official journal of American 
Society for Microbiology. 

Trips and Talks 

J. M. Martt, M.D., associate professor of the 
Department of Internal Medicine, and director of 
the Heart Station at the University of Missouri 
Medical Center, discussed the technics of car- 
diac monitoring at a meeting of the Fort Leonard 
Wood Clinical Society on February 25 in Fort 
Leonard Wood, Missouri. The discussion was il- 
lustrated by slides and actual equipment. 

Dr. David G. Hall, associate professor and 
chairman of the Department of Obstetrics and 
Gynecology, attended a meeting of the Kansas 
City Gynecological Society and Maternal Mor- 
tality Committee in Kansas City, January 16. 

Phillip J. Marco, M.D., assistant professor of 
psychiatry, and Joan L. Webb, M.D., special res- 
ident fellow in psychiatry, attended a meeting 
of the Eastern Missouri Psychiatric Association 
in St. Louis on December 5. A talk was given on 
“The Anatomy and Physiology of Sexual Be- 
havior” by Dr. William Masters, Department of 
Obstetrics and Gynecology at Washington Uni- 
versity. 

Dr. Phillip J. Marco, assistant professor of psy- 
chiatry, went to Kansas University Medical Cen- 
ter in Kansas City, Kansas, December 3, to make 
an inquiry into the psychosomatic clinical and re- 
search unit at Kansas University for the purpose 
of evaluating their program for educational use in 
developing an elective psychiatric program at the 
University of Missouri. Dr. Marco also went to 
the Missouri Psychiatric Research Institute in 
St. Louis, November 21, to inquire into research 
projects concerned with neurohormones— espe- 
cially serotonin— which at the time were of con- 
cern to the medical student and staff member 
because of the study of malignant carcinoid prob- 
lems. 

Jacob O. Sines, Ph.D., associate professor of 
clinical psychology, attended a meeting of the 
American Psychiatric Association in Iowa City-, 
Iowa, November 15 and 16. Panel discussions and 
research reports related to the development of 
a more adequate diagnostic system for use with 
children. About 100 psychiatrists, psychologists 
and social workers attended the meeting. 

Rodman P. Kabrick, Ph.D., associate professor 
of clinical psychology, represented the Missouri 
Association as a voting delegate to the National 
Association for Mental Health annual meeting 


Volume 61 
Number 3 


in Washington, D. C., November 18 through 23. 
About 2,000 professional and nonprofessional 
mental health workers attended the meeting. 

SAINT LOUIS UNIVERSITY 
Advisory Council 

Establishment of an advisory council for the 
Medical Center of St. Louis University has been 
announced by the Very Rev. Paul C. Reinert, 
S.J., University president. John P. Butler, presi- 
dent of Anderson Motor Service, Inc., was ap- 
pointed chairman. 

Other appointees are: Ben F. Jackson, senior 
partner, Price Waterhouse and Co.; H. M. Stolar, 
attorney, Stolar, Kuhlmann, Heitzmann, and 
Eder, and John M. Wolff Jr., vice president, 
Western Printing and Lithographing Co. Dr. 
George E. Thoma, associate professor of internal 
medicine at the University’s School of Medicine, 
will serve as secretary. 

In commenting on the establishment of the 
council, the Rev. Edward J. Drummond, S.J., 
vice president for the Medical Center, said he 
welcomed the outstanding experience and lead- 
ership in professional life and civic affairs the 
new appointees would bring to the Medical Cen- 
ter. 

“The Medical Center Council was established 
to provide the vice president for the Medical 
Center; the University’s board of trustees; the 
officers and faculties of the Schools of Medicine, 
Dentistry, Nursing and Health Services; and the 
Saint Louis University Hospitals with continuing 
counsel and advice on the Medical Center’s func- 
tions in which the experience of lay civic leaders 
would be most helpful,” Father Drummond said. 

“The Council will provide the administration 
of the Medical Center with experienced advice in 
all matters of business and fiscal affairs and will 
assist in the development of long-range plans for 
the physical growth of the Medical Center.” 

The Council will be composed of twelve mem- 
bers who will meet at least four times a year. Six 
additional members will be invited to join. Mem- 
bers are appointed for a three year period. 

University Hospitals Report 

The St. Louis University Hospitals 1963 an- 
nual report released by Mr. John B. Warner Jr., 
director, revealed that $11,000,000 of free pa- 
tient care was donated to the community through 
the Clinical Teaching Services of Firmin Desloge 
during the last two decades. 

This represents one third of the University 
Hospitals gross patient charges which totaled 
$32,000,000 from 1943 to 1963. 

In a comparative financial and statistical sum- 


cause 


it worked* 

in coughs 




he liked the way 
it tasted 


*By liquefying secretions in the 
respiratory tree, Cheracol made it easier 
for the patient to cough - in accord 
with the physiologic defense mechanism. 


Upjohn 


iE UPJOHN COMPANY 


236 


MISCELLANY 


Missouri Medicine 
March, 1964 


mary, the hospital operating expenses mounted 
from $324,098.95 in 1943 to $3,289,884.56 in 1963, 
representing a tenfold rise over a period of 20 
years. 

Average hospital charge per patient day rose 
from $4.81 to $39.96. While the average patient 
charge in 1963 was eight times more, the report 
indicated the hospital expenditures have in- 
creased 10 times that much. 

Patients are not remaining hospitalized as long 
as they used to. Average adult patient stay in 
1943 was 13.2 days as compared with 9.2 days 
in 1963. 

In his letter prefacing the report, Mr. Warner 
said important events of the fiscal year included 
the opening of the David P. Wohl Memorial 
Mental Health Institute, the organization of the 
Saint Louis University Hospitals staff, the adop- 
tion of a new name for the Desloge Hospital 
Guild, now known as Saint Louis University Hos- 
pitals Auxiliary and the large scale remodeling at 
Firmin Desloge. 

Major renovation projects completed included 
a $100.00 tuckpointing operation at Desloge Hos- 
pital, remodeling of patient rooms throughout the 
hospital, the innovation of an Immediate Care 
Unit on the fourth floor, expansion of the Pink 
Door Gift Shop and construction of an Optical 
Shop at Desloge Hospital for University per- 
sonnel. 

Father Reinert Honored 

The Very Rev. Paul C. Reinert, S.J., president, 
St. Louis University, was honored at a testimonial 
luncheon sponsored by four University women’s 
organizations upon his selection as the Globe- 
Democrat Man of the Year for 1963. 

The luncheon held in the Chase Club of the 
Chase Park Plaza Hotel was climaxed by an- 
nouncement of the commissioning of St. Louis 
artist Fred Conway to paint a portrait of Father 
Reinert. 

Mrs. F. Joseph Pfeffer, president, St. Louis Uni- 
versity Hospitals Auxiliary, who presided at the 
luncheon, announced that the portrait was a gift 
to Father Reinert from his many friends. 

Officers of the other cosponsoring organiza- 
tions who were seated at the head table were: 
Mrs. James V. Jones, president, the Faculty Wom- 
en’s Club; Mrs. Richard I. C. Muckerman, chair- 
man, the Women’s Council, and Mrs. D. Elliott 
O’Reilly, president, the Women’s Club of St. 
Louis University School of Medicine. 

Special guests at the head table were: Mrs. 
Raymond R. Tucker, Mrs. Donald Gunn Sr., Mrs. 
Lawrence K. Roos and Mrs. Gerald A. Rimmel. 

In outlining the plans for the University’s con- 


tinued development, particularly in the next 
five years leading up to the University’s 150th 
Anniversary in 1968, Father Reinert emphasized 
the essential role the University’s women’s or- 
ganizations will play in this development. 

More than 300 women were present at the 
luncheon. Father Reinert was the only man pres- 
ent at the affair. 

Medical Alumni Program 

An alumni reception sponsored by the Medical 
Alumni Association will be held in the Stockholm 
Room of the Park Plaza Hotel from 5:45 p.m. to 
7:15 p.m. on March 10. The reunion will be held 
in conjunction with the Missouri State Medical 
Association’s annual meeting, and is scheduled 
to precede the Past President’s dinner. 

A postgraduate program entitled “The Physio- 
logical Basis for Diagnosis and Treatment of Dis- 
ease” sponsored by the University ’s Department 
of Internal Medicine and the Missouri State Med- 
ical Association will be held in Miller Hall, Fir- 
min Desloge Hospital on Wednesday March 11. 
Sessions will begin at 10 a.m. with Dr. G. O. 
Broun Sr., dean, School of Medicine, presiding. 

Participants in the program, their subjects and 
time of presentation will be: Dr. Thomas F. 
Frawley, director, Department of Internal Med- 
icine, “New Concepts of Parathyroid Function in 
Clinical Disease,” 10:00 a.m.; Dr. Henry E. Op- 
penheimer, associate professor of clinical med- 
icine, “The Basis of Therapy of Diabetes Mel- 
litus,” 10:30 a.m.; Dr. Neil I. Gallagher, assistant 
professor of medicine, “Recent Trends in the 
Study of Iron Metabolism,” 11:00 a.m.; Dr. Gor- 
onwy O. Broun Jr., assistant professor of internal 
medicine, “Newer Concepts of the Disorders of 
Iron Metabolism,” 11:30 a.m. 

Afternoon sessions will begin at 1:30 p.m. with 
Dr. Ralph A. Kinsella Sr., Professor Emeritus, de- 
partment of internal medicine, presiding. Partici- 
pants in the program, their subjects and time of 
presentation will be: Dr. Herbert C. Sweet, pro- 
fessor of clinical medicine, “Pathophysiology and 
Therapy in Chronic Pulmonary Insufficiency,” 
1:30 p.m.; Dr. James G. Janney Jr., associate pro- 
fessor of clinical medicine, “Evaluation of the 
Hypertensive Patient,” 2:00 p.m.; Dr. R. William 
Burmeister, instructor in internal medicine, “An- 
tibiotics and Host Response in the Management 
of Infectious Disease,” 2:30 p.m.; Dr. Guy E. Van 
Goidsenhoven, assistant professor of medicine, 
“Malabsorption Syndrome,” 3:00 p.m. 

Registration fee of $10.00 includes luncheon 
in Firmin Desloge Hospital Cafeteria at 12:30 
p.m. 


ADVERTISEMENTS 


237 


When your patient says: 



help curb the smoking habit 


■ Help induce a feeling of satiety similar to 
that of tobacco because of lobeline’s phar- 
macological relationship to nicotine. 

■ Permit the patient to indulge his oral fixa- 
tion by substituting the Nikoban Pastille ■ 
for tobacco. 


■ U tilize the anorexic effect of lobeline to help 
the patient who is driven to compulsive eat- 
ing when he discontinues smoking. 

Encourage patient cooperation through 
pleasant taste. 


Dosage and Administration: In order to obtain the maximum benefit, a Nikoban Pastille should be sucked slowly and 
taken according to the schedule below. Whenever possible a pastille should be taken after meals. 

1st week: 1 pastille every 1 to 2 hours for a maximum of 12 pastilles daily. 2nd week: 1 pastille every 3 hours. 3rd week: 1 
pastille every 4 hours. 4th week: 1 pastille every 4 to 6 hours. Thereafter 1 pastille may be taken at infrequent intervals 
whenever necessary. In some instances there may at first be a slight astringent burr of the tongue and throat. This will 
usually disappear as treatment with Nikoban Pastilles progresses and is no cause for concern. 

Caution: It is advisable neither to smoke nor to use a smoking deterrent during pregnancy. 

Formulation: Each Nikoban Pastille contains 0.5 mg. lobeline sulfate in a pleasant tasting spiced-cherry base. 


Availability: In packages of 50 pastilles. 


References: 1. Goodman, L. S. and Gilman. A.: The 
Pharmacological Basis of Therapeutics, New York, 
Macmillan, 1960, Ed. 2, pp. 620-622; 2. Edmunds, 
C. W.: J. Pharmacol, and Exper. Therap., 1:27, 1909; 

3. Hazard, R. and Savini, E. Gand., 92:471, 1963. 

4. Dorsey, J. L.: Ann. Int. Med., 10:628, 1936; 5. Ras- 
mussen, K. B.: Ugeskr.laeger, 118:222, 1956; 6. Ejrup. 
B.: Sven. lak. Tid., 53:2634, 1956; 7. Jochum, K. and 
Jost, F.: Munch, med. Wchnschr., 103:618. 1961; 8. 
Jost, F. and Jochum, K.: Med. Klin., 54:1049, 1959; 
9. Smoking and Health, Summary and Report of the 
Royal College of Physicians of London on Smoking. 
New York, Pitman, 1962. 


M. R. THOMPSON, Inc., Medical Department- BB 
711 Fifth Avenue, New York, New York 10022 

Gentlemen: 

Please send me a trial supply of NIKOBAN Pastilles. 

NAME M.D. 

ADDRESS 

CITY ZONE STATE 

TYPE OF PRACTICE 


M. R. THOMPSON, INC. • NEW YORK, NEW YORK 10022 




Missouri Medicine in Review 


LEO H. POLLOCK, M.D. 



FORTY YEARS AGO 

The sixty-seventh annual session of the Associ- 
ation, which meets at Springfield, May 6, 7 and 8, 
will witness a departure from the custom that 
has been followed for so many years, and instead 
of limiting the speakers to members of the Asso- 
ciation, two eminent members of the profession 
from other parts of the country will speak. The 
program committee with the approval of the 
Executive Committee has invited John A. Ferrell, 
D.P.H., New York City, director for the United 
States of the International Health Board of Rock- 
efeller Foundation, and Dr. William Allen Pusey, 
Chicago, president-elect of the American Medi- 
cal Association. These guests will deliver ad- 
dresses at the meeting on Wednesday, May 7. 

A notable advance toward the extension of the 
teaching facilities in medicine at St. Louis was 
consummated in February when the St. Louis 
University was given control of the St. Mary’s 
Hospital group, comprising the new St. Mary’s 
Hospital now approaching completion, the St. 
Mary’s Infirmary and Mount St. Rose Sanitarium. 
These three hospitals will become a university 
hospital assuming the character of a department 
of the university. By the terms of the agreement, 
the staffs for the three hospitals will be appoint- 
ed from members of the faculty of the Medical 
School of St. Louis University, thus giving the 
control of the medical service to the staff. Hither- 
to, the appointment of the hospital staffs of the 
three institutions was under the control of the 
Sisters of St. Mary, who own the group, but the 
Sisters will not relinquish any proprietary title 
in the hospitals. This arrangement lifts the med- 
ical school of the St. Louis University into the 
class occupied by the Washington University 
with its Barnes Hospital, the Johns Hopkins Uni- 
versity with the Johns Hopkins Hospital, the 


Columbia University with the Presbyterian Hos- 
pital, and Harvard University with the Peter 
Bent Brigham Hospital. 

Health Legislation in the 68th Congress in- 
cluded H. R. 65: To Regulate Interstate Traffic in 
Sutures and Surgical Ligature Material. The 
shipment between the states of any suture or 
ligature material for human surgical use must 
bear a label showing that such material has been 
sterilized, under the provisions of this measure; 
it provides that any officer of the Treasury De- 
partment detailed for that purpose, may enter 
and inspect any establishment where sutures or 
ligature material for human surgical use is pre- 
pared or packed; it establishes a Board consist- 
ing of the surgeons general of the Navy, Army 
and Public Health Service to establish regula- 
tions on this general subject. 

TWENTY-FIVE YEARS AGO 

Three hundred million dollars is alleged to be 
spent in this country annually for drugs which 
will produce an evacuation of the bowels. Such 
preparations are in great demand by persons who 
will not realize that there is no alarm clock in 
the intestinal tract. Furthermore, these persons, 
impelled by clever advertisers, remain convinced 
that a daily movement is necessary to health. 

TEN YEARS AGO 

Six father-and-son pairs of physicians, all now 
of St. John’s Hospital (St. Louis) staff, attended 
the Hospital’s sixteenth annual Christmas dinner 
for its doctors on Thursday evening, December 
10. The twelve two-generation medical men are: 
Dr. Joseph P. Costello, Dr. Joseph C. Peden, 
Dr. Charles H. Neilson, Dr. Augustus P. Munsch, 
Dr. Linus M. Ryan, and Dr. Otto V. Lieb, and 
their sons: Dr. Joseph P. Costello Jr.; Dr. Joseph 
C. Peden Jr.; Dr. Arthur W. Neilson, Dr. Girard 
A. Munsch, Dr. Robert E. Ryan, and Dr. Fran- 
cis A. Lieb. This preholiday affair is given each 
year as a gesture of appreciation by the Sisters 
of Mercy who have conducted St. John’s Hospital 
since is establishment in 1871. Dr. Grayson Car- 
roll, Associate Chief of Staff, was the toastmaster. 

Kansas City radiologists were much in evi- 
dence at the 39th Annual Meeting of the Radi- 
ological Society of North America in Chicago 
late in December. Ira H. Lockwood, M.D., pre- 
(Continued on page 244) 


238 


Contents for April 1964 

Scientific Articles: 

University of Missouri Medical Center, 
Vernon E. Wilson, M.D., Columbia . . 273 

Development of a New Curriculum at the 
University of Missouri School of Medi- 
cine, William D. Mayer, M.D., Columbia 279 

A Computer in Medicine, Donald A. B. 
Lindberg, M.D., Columbia .... 282 

Irradiation in the Management of Peptic 
Ulcer, G. R. Ridings, M.D., Columbia . 285 

Chromosomes and Human Disease, Wil- 
liam V. Miller, Columbia 288 

Clinical Experience With Gastric Hypo- 
thermia in the Treatment of Upper Gas- 
trointestinal Hemorrhage, John H. Lan- 
dor, M.D., and W. Kermit Baker, M.D.. 
Columbia 292 


Special Article: 

A Proper Reference, Robert Q. Marston, 

M.D., Jackson, Miss 298 

Departmental Features: 

Washington 258 

Across Missouri 260 

Missouri Academy of General Practice . 264 

Component Societies in Affiliation With the 
Missouri State Medical Association . . 268 

Womans Auxiliary 270 

President’s Message 302 

Editorial 303 

Ramblings of the Field Secretary . . . 304 

News-Personal and Professional . . . 308 

New Members 310 

Deaths 312 

County Society News 314 

From the Medical Schools 320 


Editorial and Business Office, 634 N. Grand Blvd., St. Louis 3, Mo. Copyright 1964 by Missouri State Medical Association. All 
rights reserved. Second-class postage paid at Fulton, Missouri. Published monthly, except semi-monthly in July, by the Missouri 
State Medical Association at 1201-05 Bluff Street, Fulton, Missouri. Subscription Price: $3.00 Per Year. Printed by The Ovid 
Bell Press, Inc., Fulton, Missouri. 


Information for Contributors 


Articles are accepted for publication on condi- 
tion that they are contributed solely to this jour- 
nal. Material appearing in Missouri Medicine is 
protected by copyright. Permission will be granted 
on request for reproduction in reputable publica- 
tions provided proper credit is given and author 
gives permission. 

Manuscripts should be typewritten, double 
spaced, and the original with one carbon copy sub- 
mitted. Retain another carbon copy for proofread- 
ing. Used manuscripts are not returned. School and 
hospital appointments of the author should ac- 
company the manuscript. It is desirable that a 
synopsis- abstract of approximately 135 words ac- 
company the manuscript. Bibliography should be 
arranged at the end of the article in the order in 
winch the references are cited in the text. The 
reference should give name of author, title of ar- 
ticle, name of periodical, volume number, initial 
page number and year. Authors are responsible 
for bibliographic accuracy. Bibliography should 
be double spaced. 

Illustrations should be glossy prints or draw- 
ings in India ink on white paper. They should 


not be mounted and name of author and figure 
number should be penciled lightly on the backs. 
Legends should appear on a separate sheet. 
Colored illustrations will be used when suitable 
if author assumes the actual cost. 

Legal difficulties may arise from unauthorized 
use of names, initials or photographs in which in- 
dividuals can be identified. Permission should be 
secured from patient or legal guardian and signed 
duplicate or photostat submitted with such photo- 
graphs or identification. The Editor and Editorial 
Board assume no responsibility for the opinions 
and claims expressed in articles contributed by 
authors. If citation of an institution related to the 
article is made, approval of the chief of service 
should be given in a letter accompanying the 
article. 

Reprint order blanks will accompany proof, 
which will be sent to authors prior to publication. 

All material other than scientific should be re- 
ceived prior to the first of the month preceding 
month of publication. 

Please give notice of change of address at least 
one month in advance of the change, giving old 
and new addresses. 


257 



Medical Aid Grab-Bag 

On February 17, the St. Louis Globe-Demo- 
crat summed up an opinion of the situation 
under President Johnson of the medical care of 
the elderly as follows: 

“In the health program he has submitted to 
Congress President Johnson has wrapped up in 
one package anything left over from the New 
Deal, the Fair Deal and the New Frontier— and 
stamped his LBJ brand on it. 

“As with the war against poverty and the cru- 
sade to protect the consumer he has tossed into 
the hopper for this election year, Mr. Johnson 
doesn’t offer anything particularly new in his 
health program. His ‘idea man’ only went to 
work last week. 

“But by now there can be no doubt that any- 
thing branded LBJ is sure to be comprehensive! 
# * # 

“Was the Kennedy program to provide Medi- 
care for persons over 65 through Social Security 
inadequate, because it made no provision for 
those not covered by Social Security? 

“The LBJ program easily takes care of that. 
Persons who don’t pay Social Security taxes, and 
won’t pay more if medical insurance is included, 
will get the same benefits for free— the money to 
come from the ‘administrative budget’ to which 
all taxpayers contribute. 

“Was the Kennedy Administration, seeking 
Medicare, cool to the Kerr-Mills program under 
which the states, aided with Federal funds, can 
provide for the medically indigent? 

“No one can raise that objection to the LBJ 
program. The President urges more states to 
avail themselves of the Kerr-Mills law as a ‘sup- 


plement’ to the Federal hospital insurance he 
proposes for those both under and outside Social ( 
Security. 

# « 

“Was the original Medicare proposal a threat 
to private health insurance plans through which 
Americans could make provision themselves for 
their old age? 

“That’s taken care of, too, under the LBJ pro- 
gram. The President says it will provide ‘a base 
that related private programs can supplement.’ 
Thus persons who have any money left after 
their taxes have paid for both Medicare and 
Kerr-Mills can get three-way medical protec- 
tion for their own old age. 

“Not, of course, that the frugal Mr. Johnson 
stresses the money involved as he offers the 
American people his panaceas for all their ills 
and needs the New Deal, Fair Deal and New 
Frontier didn’t take care of. 

* * * 


“Medicare as proposed by the late President 
Kennedy, which didn’t make provision for one- 
third of the American people not under Social 
Security, was estimated to cost $5,000,000,000 
during the first five years. 

“To the LBJ program would have to be added 
at least one-third more to provide for those to be 
given free the benefits others were paying higher 
Social Security taxes for. 

“Nor is that all. 

“In his ‘vigorous and many-sided attack on 
our most serious health problems,’ Mr. Johnson 
has included a lot of incidentals which must 
have been overlooked before by accident. 

“Among the many sides would be Federal 
spending for schools of nursing, for group-prac- 
tice medical and dental facilities, for renovating 
older hospitals in the larger cities, for vocational 
rehabilitation programs, for preventing and con- 
trolling air pollution, for pesticides control, nar- 
cotics control, etc., etc., etc.!” 


258 







disability without debilitation 



supportive oral anabolic therapy • potent • well-tolerated 


Disabling illness or injury at any time of life can invite a slowdown in the natural anabolic processes 
or acceleration of catabolic processes, resulting in a "wasting" of protein and minerals needed for 
tissue repair. Loss of weight and appetite, strength and vitality, may be the evident signs of this 
process, frequently accompanied by a lowering of mood, interest and activity. The older the patient, 
the more pronounced may be the signs of debilitation. A potent, well-tolerated anabolic agent plus 
a diet high in protein can make a remarkable difference. 


WINSTROL* brand of STANOZOLOL 


...a new oral anabolic agent, combines high ana- 
bolic activity with outstanding tolerance. Although 
its androgenic influence is extremely low*, women 
and children should be observed for signs of slight 
virilization (hirsutism, acne or voice change), and 
young women may experience milder or shorter 
menstrual periods. These effects are reversible when 
dosage is decreased or therapy discontinued. Patients 
with impaired cardiac or renal function should be 
observed because of the possibility of sodium and 
water retention. Liver function tests may reveal an 
increase in BSP retention, particularly in elderly 

•The therapeutic value of anabolic agents depends on the ratio of 
anabolic potency to androgenic effect. This anabolic-androgenic 
activity ratio of Winstrol is greater than that of all the oral anabolic 
agents currently in use. 


patients, in which case therapy should be discon- 
tinued. Although it has been used in patients with 
cancer of the prostate, its mild androgenic activity 
is considered by some investigators to be a 
contraindication. 

Dosage in adults, usually 1 tablet t.i.d.; young wo- 
men, 7 tablet b.i.d.; children (school age), up to 1 
tablet t.i.d.; children (pre-school age), V 2 tablet b.i.d. 
Shows best results when administered with a high 
protein diet. Available as scored tablets of 2 mg. in 
bottles of 100. 

W/nfhro p 

Winthrop Laboratories, New York, N. Y. 





Missouri High in Health 
Insurance Protection 

Missourians have reached a high level in 
health insurance protection, according to a re- 
cent report by the Health Insurance Institute. 
The latest inclusive figures by the Institute are 
for the year 1962. 

As of Dec. 31, 1962, 85 per cent of the state’s 
population were covered by some form of health 
insurance for the costs of hospital and medical 
care. This compares with the national figure of 
76 per cent of the civilian population— some 141 
million persons— having health insurance. 

Some figures as of the 1962 date included the 
number of persons with hospital expense insur- 
ance, 3,710,000; number of persons with surgical 
expense insurance, 3,378,000; number of persons 
with regular medical expense insurance, 2,523,- 
000; number of persons with major medical in- 
surance, 840,000; total health insurance benefits 
paid in 1961, $146,650,000.00. 

The amount paid by insurance companies for 
hospital, surgical and medical care, including 
loss of income was $81,999,000.00. That paid by 
Blue Cross-Blue Shield and other plans for hos- 
pital, medical and surgical care was $64,651,- 
000 . 00 . 

The number of health insuring organizations 
licensed in the state was 276. This total was 
made up of 251 insurance companies, four Blue 


Cross-Blue Shield and similar groups and 21 
other health plans. 

Hospital Statistics 

The number of non-federal, short term general 
and other hospitals in the state at the end of 
1962 numbered 110; the number of hospital beds 
available was 17,294. The number of persons ad- 
mitted to hospitals during the year 1962 was 
573,709. The number of persons under hospital 
confinement on an average day was 13,179. The 
average length of time a patient remained in 
the hospital was eight days. The average cost 
per hospital stay was $275.98. 

Professional Services 

The number of practicing physicians in Mis- 
souri at the end of 1962 is given as 3,441; the 
number of practicing dentists was 2,426, and the 
number of registered pharmacists was 2,790. 

Present Day Estimates 

A recent estimate by the Health Insurance 
Institutes gives 145 million as the number of 
persons covered today by insurance. 

Among newer type insurance coverage is nurs- 
ing home care and more than 30 companies 
specifically offer this type of care. 

Approximately 1.2 million people were cov- 
ered by insurance for dental care in 1962, more 
than double the number in 1960. The number of 
plans offering coverage for dental care is esti- 
mated to be more than 300. 

Long-term disability available on an individ- 
ual basis is expected to grow at an accelerated 
rate in 1964 under group insuring mechanism. 
This provides benefits to help replace income 
lost by the wage-earner as a result of disability 
for a minimum of five years. 

Insurance for the elderly is one of the fastest 
growing types of insurance. More than 200 com- 
panies as well as many Blue Cross and Blue 
Shield plans offer health insurance plans for the 
aged. Ninety-five companies and associations 
provide guaranteed for life policies under 191 
policies and plans. About 10.3 million aged per- 
sons had health insurance at the end of 1962— 
60 per cent of the 65 and over segment of the 
non-institutionalized aged population. 


260 


\ Effects : Since it may, under some circumstances, 
jjuce many of the unwanted effects common to all 
isone-like drugs, discrimination should always be 
•cised in administering ARISTOCORT® Triamcino- 
Any of the Cushingoid effects are possible, as are 
bura, G.l. ulceration, increased intracranial pres- 
: and subcapsular cataract. Corticosteroids gen- 
ly may mask outward signs of bacterial or viral 
ictions. Catabolic effects to watch for include 
.icle weakness and osteoporosis. Weight loss may 
jr early in treatment but is usually self-limiting. 
traindications: While the only absolute contra- 
ctions are tuberculosis, herpes simplex and 
ken pox, there are some relative contraindications 
otic ulcer, acute glomerulonephritis, myasthenia 


gravis, osteoporosis, fresh intestinal anastomoses, 
diverticulitis, thrombophlebitis, psychic disturbance, 
pregnancy, infection) to weigh against expected 
benefits. 

Why not consider ARISTOCORT® Triamcinolone when 
you are contemplating steroid therapy? Both you and 
your patient will be gratified with the results. 


MAXIMUM STEROID BENEFIT- MINIMUM STEROID PENALTY 



Triamcinolone 


1 mg., 2 mg., 4 mg. or 16 mg. tablets 


ERLE LABORATORIES • A Division of AMERICAN CYANAMID COMPANY, Pearl River, New York 


270-4 



C. G. STAUFFACHER, M.D., Secretary 


Missouri Academy of General Practice 


The 16th Annual Scientific Assembly of the 
AAGP will be held in Atlantic City April 13-16, 
1964. The meeting will be housed at Atlantic 
City’s Convention Hall and will feature 31 speak- 
ers and more than 110 scientific exhibits. 

The theme of the 1964 assembly will be, “The 
Family in Medical Perspective.” Says the AAGP, 
“The family theme stems from growing recogni- 
tion that if the family doctor is to provide com- 
prehensive health care for the whole family, he 
must be alert and trained to view his patients in 
the light of their environment. 

“This means that his care must transcend the 
basic medical sciences and mere diagnosis and 
therapy, and involve application of the behav- 
ioral sciences— anthropology, psychology and so- 
ciology. The patient is a family member and the 
changes in behavioral patterns within the close- 
knit family situation can have tremendous im- 
pact on health.” 

With the foregoing in mind, a four physician 
panel, two of whose members are working fam- 
ily doctors, will discuss four specific questions 
on the opening session on Monday afternoon, 
April 13. These questions will be: What are the 
medical needs of the family? What effects do 
behavioral changes in family life, mores, eco- 
nomics and religion have on these medical 
needs? How, and how well, does the family doc- 
tor provide family medical care? What special 
qualifications must the family doctor have to 
cope with behavioral modifications of family 
health problems? 


Following consideration of sociological aspects 
of family practice, the program will cover, 
through top national authorities, a wide spec- 
trum of physical problems confronting the family 
doctor. Among these will be a symposium on 
newest technics in endocrinology, a panel on 
breast tumors, G.I. tract anomalies in the new- 
born child and defective hearing. Additional 
topics include diagnosis in heart disease and in 
collagen disorders, occupational medicine, episi- 
otomy, soft-tissue radiology, puzzling infant 
rashes, sinusitis, post-infectious hepatic functions 
and the mouth as an indicator of general health. 

The causes and impact of a rising incidence 
of venereal disease, especially in youth, will be 
explored in detail in a panel discussion on the 
closing program, Thursday morning, April 16. 

The climaxing social event will be held on 
Wednesday night, April 15, with the President’s 
Reception and Dance, immediately following the 
inauguration of incoming President Julius Mi- 
chaelson of Foley, Ala. 

Attendance at the scientific assembly is valued 
at 14 hours of postgraduate study. 

The AAGP policy making Congress of Dele- 
gates will convene on Saturday, April 11, at the 
Shelburne Hotel in Atlantic City 7 . The Missouri 
Academy delegates, who will take part in the de- 
liberations of the Congress of Delegates, are 
Charles O. Metz, M.D., St. Louis, and C. G. 
Stauffacher, M.D., Sedalia. Alternate Delegates 
from Missouri are Walter T. Gunn, M.D., St. 
Louis, and Edson C. Carrier, M.D., Kansas City. 


264 






the original brand of 
meprobamate 


The insomniac 


The tense, nervous patient 


The heart-disease patient 


The surgical patient 


’ menstrual tension 


The agitated senile patient 


WALLACE LABORATORIES 
Cranbury, N.J. 


The G.I. patient 


(girl with dermatosis 


Tension headache 


The problem child 


The woman in menopause 


Jkt, 

Anxious depression 


Component Societies in Affiliation With the 
Missouri State Medical Association 


County 

District 

President 

Address 

Secretary 

Address 

Andrew 

... 1 

, .V. R. Wilson 




Audrain 

... 5 

. . Harry F. O’Brien 




Barton-Dade 

. . . 8 

. . Herbert M. Arnold . . . 


. . . T. W. Carroll 


Benton 

. . . 6 



James A. Logan .... 


Boone 

... 5 

,.Jack M. Martt 




Buchanan 

... 1 

..Herbert C. Senne 




Butler-Wayne-Ripley 

. . .10 

.James H. Turner 


. . . Wm. D. Robertson . . 


Callaway 

... 5 

.William J. Cremer ... 




Cape Girardeau 

. . .10 

. Wm. O. L. Seabaugh . . 


. . . Joseph E. Hecker .... 


Carter-Shannon 

... 9 

. H. D. Rollins 




Chariton-Macon-Monroe- 
Randolph 

... 2 

. Thomas S. Fleming . . . 



. . . . Moberly 

Clay 

... 1 

. Edward H. Fischer . . . 



. . . . Liberty 

Clinton 

... 1 

. W. B. Spaulding 


. . . J. P. Mabrey 


Cole 

.. . 5 

. .G. D. Shull 


. . . F. O. Tietjen 

. . . . Jefferson City 

Cooper 

... 5 

. T. C. Beckett 




Dallas-Hiekory-Polk 

. . . 8 

. Ben H. Koon 


. . . Evelyn Griffin 


Dunklin 

. . .10 

. J. Owen Swafford 




Franklin-Gasconade-Warren 

.. 4 

. B. P. Eisenmann 



. . . . Hermann 


Grand River Medical Society 
( Caldwell-Livingston-Carroll- 
Grundy-Daviess-Harrison- 


Linn-Mercer-DeKalb) 

1 ... 

. . .James H. Sweiger .... 



8. . . 



Henry 

6 . . . 

. . . J. O. Smith 


Howard 

5 . . . 



Jackson 

7 . . . 




8. . . 



J efferson 

4. . . 

. . . F. L. Kozal 


Johnson 

6 . . . 

. . . A. L. Folkner 


Lafayette-Ray 

6 ... 

. . . Wilbur E. Fulkerson 

. . . Higginsville. 

Lewis-Clark-Scotland 

2 ... 

. . . Earl Gilfillan 


Lincoln-St. Charles 

4 . . . 

. . . Vincent Muenster 


Marion-Ralls-Shelby 

2 ... 

. . . Wyeth Hamlin 


Mid-Missouri County Medical 
Society (Phelps-Crawford- 
Dent-Pulaski-Maries-Laclede ) 

9 ... 

. . . Rae W. Froelich 

. . . Lebanon .... 


, R. S. Hollingsworth Clinton 


, William LaHue Lexington 


Hannibal John H. Walterscheid ...Hannibal 


Miller 5 C. T. Buehler Eldon 

Mineral Area County Medical 
Society (St. Francois-Iron- 
Madison-Washington- 

Reynolds) 10 A. G. Karraker Farmington C. W. Chastain Farmington 

Moniteau 5 K. S. Latham California L. M. Gallagher California 

Montgomery 5 E. J. T. Andersen Montgomery City ...Samuel J. Byland Wellsville 

Morgan 5 Jack Gunn Versailles J. Loren Washburn Versailles 


Nodaway-Holt- Atchison- 

Gentry-Worth 1 John M. Wanamaker Rock Port Frank B. Matteson Grant City 

North Central Counties Medical 
Society ( Adair-Schuyler- 

Knox-Sullivan-Putnam ) .... 2 Paul E. Hilton Kirksville Edward M. Grim Kirksville 


Ozarks Medical Society 
(Barry-Lawrence-Stone- 
Christian-Taney-Newton- 

McDonald) 8 William J. Glass Jr Monett Paul B. Anderson Neosho 


Pemiscot 10 J. D. Caldwell Hayti James Barnard ... 

Perry-Ste. Genevieve 10 Oscar Carron Perry ville Joseph Lutkewitte 

Pettis 6 Thomas J. Hopkins Sedalia E. M. Braverman 

Pike 2 W. Joe Martin Louisiana E. K. Jackson .... 

Platte 1 H. Graham Parker Platte City H. C. Thurman . . . 


Caruthers ville 
Ste. Genevieve 
Sedalia 
Clarksville 
Parkville 


St. Louis City 3 David N. Kerr . 

St. Louis County 4 James R. Nakada 

Saline 6 Marvin Rohrs .. 

Semo County Medical Society 
(Stoddard-New Madrid- 

Mississippi-Scott) ..10 John Dernoncourt 

South Central Counties Medical 
Society ( Howell-Oregon- 
Texas- W right-Douglas- 

Ozark) 9 Amos L. Coffee .. 


St. Louis Richard V. Bradley St. Louis 

St. Louis C. Howe Eller St. Louis 

Marshall R. C. Haynes Marshall 


Charleston Thelma C. Buckthorpe .... Sikeston 


Willow Springs .... Rollin H. Smith West Plains 


Webster 8 

West Central Missouri Medical 
Society (Bates-Cass-Cedar- 
St. Clair-Vernon) 6 


C. R. Macdonnell Marshfield 

Carter W. Luter Butler 


. . . E. G. Beers Seymour 

. . . Roy W. Pearse Nevada 


268 


ADVERTISEMENTS 


269 



why does 
150 mg. 



do more than 
250 mg. 



of other 
tetracyclines? 


Because it has up to 31/2 times the in vitro antibacterial activity' .. .combined with 
lower rate of decay in serum, slower renal clearance ... a favorable depot effect, result- 
ing from protein binding. . .all providing rapid, higher and sustained in v/Vo activity with 
as much as 2 days’ extra activity. 



jjeclom vcrN 


DEMETHYLCHLORTETRACYCLINE HCI 

Effective in a wide range of everyday infections— respiratory, urinary tract and others— in the young 
and aged— the acutely or chronically ill— when the offending organisms are tetracycline-sensitive. 
Side Effects typical of tetracyclines which may occur: glossitis, stomatitis, proctitis, nausea, diar- 
rhea, vaginitis, dermatitis, overgrowth of nonsusceptible organisms. Also: photodynamic reaction 
(making avoidance of direct sunlight advisable) and, very rarely, anaphylactoid reaction. Reduce 
dosage in impaired renal function. The possibility of tooth discoloration during development should 
be considered in administering any tetracycline in the last trimester of pregnancy, in the neonatal 
period, and in early childhood. Capsules, 150 mg. and 75 mg. of demethylchlortetracycline HCI. 
Average Adult Daily Dosage: 150 mg. q.i.d. or 300 mg. b.i.d. 1. Sweeney, W. M.; Dornbush, A. C. ( 
and Hardy, S. M.: Demethylchlortetracycline and Tetracycline Compared. Relative in vitro Activity 
and Comparative Serum Concentrations During 7 Days of Continuous Therapy. Amer. J. Med. Sci. 
243:296 (Mar.) 1962. 


LEDERLE LABORATORIES, A Division of AMERICAN CVANAMID COMPANY, Pearl River, New York 

75163 








Woman’s Auxiliary 



I begin my first communication to you a bit 
stiff in my writing joints and my cerebral reflexes. 
As the year progresses I hope these functions 
will improve. You are aware that these first ex- 
pressions precede my installation by some two 
weeks, hence concrete reports on our convention 
in St. Louis will come later. 

I have raised a family of four, chased their 
sports activities, worked at school, church and 
civic matters, rooted for 
citizenship— the works! As 
a native Missourian whose 
home has always remained 
in the state we have en- 
joyed the lakes, the hills 
and bluffs, the universities, 
but now I am learning to 
know my Missouri through 
its auxiliaries and look to 
the coming year with 
pleasure. As a former nurs- 
ing supervisor I loved the 
medical field and our devoted and dedicated 
doctors. Auxiliary work has naturally always 
been a major interest of mine. 

For any of you who may not be aware of the 
vigor and devotion that Jane Crispell has put 
into all her work for the Auxiliary let me state 
the case for you. A dedicated person, she has 
been wonderfully effective at details with an 
active correspondence, accurate reporting and 
note keeping in her struggle to ease my path 
into office. My shortcomings will be less evident 
because of her efforts and, Jane, I sincerely ap- 
preciate all these things that will be passed 
along to my successor. 

During the year Jane and I attended our State 
Convention in Kansas City, the St. Louis County 
Auxiliary for Dotty Deyton’s installation and 
then we were guests at the Illinois State Meeting 
in Chicago along with presidents and presidents- 
elect from Michigan, Wisconsin, Indiana and 
Kentucky. It was nice to arrive at National Con- 
vention at Atlantic City in June and see familiar 
faces from five states. In September I was a 
guest at the Kentucky State meeting in Lexing- 
ton. These experiences in hearing the progress 
and problems of other state auxiliaries and meet- 


ing other doctors’ wives is of incalculable value. 
Both the National Conference in Chicago and 
our own Fall Conference in Joplin during Octo- 
ber were constructive. 

The National theme of “Serve and Communi- 
cate’’ has been carried out in many ways by all 
the auxiliaries. A doctor-lawyer dinner in Pettis 
County, Cape Girardeau made puppets for the 
pupils of the Handicapped Training Center, 
Marion-Ralls-Shelby sponsored a Refresher 
Course for Nurses and helped put over the first 
Sabin Oral Sunday in the state. Audrain County 
helped with the crippled children’s Easter seal 
drive, Jasper granted two $500.00 nurses’ scholar- 
ships, Boone County’s biggest project is aiding 
the Red Cross in its volunteer blood procure- 
ment program. Buchanan has four Health Ca- 
reer Clubs going with each club having two 
Auxiliary members as advisers. The film “Cry 
for Help” was shown to representatives from 
the welfare agencies and other organizations in- 
terested in mental health by Jackson County. 
Cole County gave a tea for the wives of lawyers, 
pharmacists and dentists, Lafayette-Ray pro- 
moted teaching classes in Medical Self Help 
Education, Callaway County carried out a proj- 
ect for the tuberculosis ward at the State Hos- 
pital and the chronic ward at the Callaway Hos- 
pital. Johnson County helped in the dedication 
of the new Johnson County Memorial Hospital. 
St. Louis City and St. Louis County helped with 
the massive Oral Sabin Immunization and staffed 
Tuberculosis Mobile X-Ray units. Mineral Area 
sponsored the showing at two theaters of 
the films “Self Breast Examination” and “Time 
and Two Women.” Clay County sponsored four 
Health Career Clubs which are active and will 
give a $300.00 scholarship. Butler-Ripley- Wayne 
sponsored the Medical Self Help program for a 
six weeks course in conjunction with the Civil 
Defense Department. Grand River appointed a 
committee to help select a worthy student to 
benefit from their health career fund. Dunklin 
gave assistance to the South Missouri Mental 
Health Center, MAL’s working with Rural ser- 
vice organizations, PTA’s and Civil defense 
groups. Saline County raised funds for AMA- 
(Continued on page 308) 



270 



Volume 61, Number A — April, 1964 


Missouri Medicine 


JOURNAL OF THE MISSOURI STATE MEDICAL ASSOCIATION 


Copyright, 1964 by Missouri State Medical Association. All Rights Reserved. 


VERNON E. WILSON, M.D., Columbia 


University of Missouri Medical Center 

A Progress Report 


Indebtedness to the Missouri State Medical As- 
sociation for the opportunity of presenting this 
fifth annual report of activities of the University 
of Missouri School of Medicine is acknowledged. 
The many persons who collectively through state 
organizations or individually have aided the new 
and rapidly growing institution in Columbia are 
so numerous as to defy an individual mentioning 
of each name. Suffice it so say that whatever 
success has been achieved has resulted in large 
measure from the fine and concerted support 
rendered by the State Medical Association, the 
Academy of General Practice, the Alumni As- 
sociation and the several state and private agen- 
cies with whom it has been our privilege to co- 
operate during this period of time. 

The single most important element in the suc- 
cess of any institution or organization is the 
people in it. This is particularly true, I believe, 
for a school of medicine. Our product is people— 
highly trained individuals who will help to meet 
the needs of the communities for health care. 
Their study is directed to people, people with 
medical problems. Thus, it seems appropriate in 
a review of the institution to discuss first the 
patients who came to the Medical Center during 
the last year. 

Patients 

Patients continue to come regularly from al- 
most all of the 114 counties of the state. Last 
year there were approximately 10,000 admissions 


Changes in personnel and in operational 
procedures are outlined, showing the prog- 
ress that is being made and that has been 
made during the eight years of existence of 
the four year medical school at Columbia. 

Dr. Wilson is Dean and Director of the 
University of Missouri School of Medicine. 


to the hospital and 60,000 visits to the Outpatient 
Clinics. A high percentage of the patients coming 
to the clinics and to the hospital are first admis- 
sions, which has made their care a rich source 
of instruction for the education of students and 
resident staff. Physicians of the state have, for 
the most part, responded magnificently to the 
need of the school by selective referral of pa- 
tients who will provide the best possible teaching 
experience. 

Because of the growing demand, it was not 
possible this year to accept all patients who 
were referred. Preference in such instances is 
given to the individual whose medical prob- 
lem will lend itself to a comparatively brief treat- 
ment period and who would seem to particularly 
need the resources of a large and complicated 
medical center. A proportion of chronic illness 
is accepted in order that the cross-section of 
health care given should be representative of 
that which is needed in the community . All pa- 
tients continue to be accepted only upon referral 


274 


UNIVERSITY OF MISSOURI MEDICAL CENTER— WILSON 


Missouri Medicine 
April, 1964 


of their family physician. We are aware that 
communications regarding return visits still need 
improvement and are working diligently to pro- 
vide this. 

Outpatient Clinics— Although the rapidly- 
growing number of individuals coming to the 
Outpatient Clinic, and the time involved in their 
care has in part prohibited the staff from setting 
up a completely smoothly functioning organiza- 
tion in that area, this is the goal in the interest 
of all concerned. Every attempt is being made 
to provide each patient with personalized treat- 
ment. In addition, the Outpatient Clinic Com- 
mittee is now working out details of a system 
which they hope will assure the patient of an 
individualized series of appointments upon his 
scheduled arrival in the Clinics, and thus help to 
reduce the amount of waiting time which is 
sometimes required now. Considerable emphasis 
is being placed upon developing a system which 
will give immediate information back to the re- 
ferring physician following an outpatient visit, 
although this is a relatively difficult procedure 
to initiate and to carry out routinely. 

Student Body 

For each of the five years of these annual re- 
ports, the total number of applications to the 
School of Medicine has continued to increase. 
This year, more than 600 applications were sub- 
mitted. Two hundred and eighty-five applicants 
were interviewed at the Medical School. All resi- 
dents of the State of Missouri who made appli- 
cation were invited to come for an interview. 

We are particularly indebted to the State 
Medical Association and to alumni for stimulat- 
ing the interest of students throughout the state 
in attending the University of Missouri, and hope 
that we may continue to have their support. 

The Admissions Committee has been im- 
pressed both with the high caliber of individuals 
who indicated an interest in attending the Uni- 
versity of Missouri and the general level of their 
academic performance in premedical work. Be- 
cause of the increasing academic proficiency of 
the incoming classes, it is the belief of the faculty 
that an even higher percentage of these first year 
students will graduate, which obviously gives 
an increase in the number of physicians who can 
enter practice in the state. Eighty-five students 
are now being admitted into each first year class. 
It will not be possible to take more students until 
more class room and laboratory space is made 
available. In addition, more faculty would need 
to be hired, and thus more office and research 


space would be required. Fortunately, the 
amount of patient care being given in the hos- 
pital would support a larger student body; conse- 
quently, limitation at the moment rests with class 
room and faculty space where expansion is ur- 
gently needed. 

Faculty 

The last year has brought a number of changes 
and some major additions to the School of Medi- 
cine faculty. 

It was with deep regret that the University an- 
nounced in July that Dr. John J. Modlin, who 
had served as Chairman of the Department of 
Surgery since January of 1961, would be relin- 
quishing his post as of January 1, 1964, to re- 
enter the private practice of surgery in Colum- 
bia. Under Dr. Modlin’s excellent leadership, the 
Department of Surgery had filled all of its spe- 
cialty areas and had made great progress in 
achieving its role as an academic arm of the 
University. His many patients and friends are of 
course delighted to have him return to private 
practice, and he will be retaining his appoint- 
ment as a teacher on the faculty and will con- 
tinue to participate on a volunteer basis in that 
role. 

The school has been fortunate indeed in being 
able to attract to this post Dr. Marion S. De- 
Weese from the University of Michigan. Dr. De- 
Weese has been a member of that faculty’ since 
1948 and has achieved an outstanding national 
and local reputation as a teacher and clinician. 
He has an extensive bibliography as a result of 
his investigative work, and under his leadership 
the Department of Surgery can be expected to 
continue to grow and to further enhance its 
academic program. 

During the interim period until Dr. DeWeese s 
arrival in June, Dr. John F. Patton has assumed 
the direction of that department as Acting Chair- 
man. Dr. Patton, wdio retired recently as a Colo- 
nel in the United States Army Medical Corps, 
was formerly Chief of Surgery at Walter Reed 
Hospital in Washington, D. C. He is a native 
born Missourian, who has returned to this state 
for his retirement. Following Dr. DeWeese’s 
arrival, Dr. Patton will continue on the faculty 
in the Section of Urology, wdiere he will serve 
on a part time basis. 

William D. Bryant, Ph.D., wdio has been Di- 
rector of the Community 7 Studies group in Kansas 
City, has accepted a post as of January 1 as As- 
sistant Dean and Coordinator for Medical Re- 
search in the Medical Center. He is well know n 


Volume 61 
Number 4 


UNIVERSITY OF MISSOURI MEDICAL CENTER— WILSON 


275 


to individuals in the Kansas City area, and the 
School looks forward with pleasure to his many 
contributions in the field of research develop- 
ment. 

Dr. William D. Mayer, who has been serving 
half time in the Dean’s Office and half time in 
the Department of Pathology, will be coming to 
the Dean’s Office on a full time basis as of July 1. 
At that time, he will assume the academic re- 
sponsibilities which are being relinquished by 
Dr. G. S. Lodwick. A new Assistant Dean for 
Student Affairs is being sought to fill Dr. Mayer’s 
present position. 

Dr. G. S. Lodwick, Chairman of the Depart- 
ment of Radiology and Associate Dean in the 
School of Medicine, has returned to full time 
activities in the Department of Radiology, effec- 
tive January 1. Dr. Lodwick served as Acting 
Dean in the interim period in 1959 and continued 
in the Dean’s office on a half time basis as As- 
sociate Dean until the present time. As the 
School and the Medical Center continue to grow, 
he has found it increasingly difficult to maintain 
efforts in the two areas and has chosen this 
year to return full time to radiology for the bene- 
fit of the further development of the academic 
research programs in that department. The 
School of Medicine and the University are deep- 
ly indebted to Dr. Lodwick for the fine leader- 
ship which he has given to the School and for the 
many contributions he has made, not alone to 
the programs of the Medical Center, but to those 
in the general University as well. He will, of 
course, continue to serve on the executive faculty 
and on numerous statewide endeavors represent- 
ing the School of Medicine. 

Dr. William H. Anderson has recently been 
appointed as associate professor of psychiatry 
and will become superintendent of the new Mid- 
Missouri Mental Health Center when it begins 
operation. Dr. Anderson was a Colonel in the 
Army and has retired from the service and his 
post as Chief of the Department of Psychiatry 
and Neurology at Walter Reed Hospital to as- 
sume this new position. He will function as a 
member of the Department of Psychiatry under 
Dr. James M. A. Weiss, Chairman of that De- 
partment. Both the State Division of Mental 
Diseases and the University feel they were fortu- 
nate in being able to attract a person of his abil- 
ity to this most important post. 

Dr. Sherwood Baker came to the University of 
Missouri in October of last year as the first full 
time individual specifically representing general 
practice. He has been in general practice for a 


period of 17 years in Mount Morris, 111., and 
came to the University as Chief of the Section of 
General Practice in the Department of Com- 
munity Health and Medical Practice. He will be 
in charge of the General Practice Residency pro- 
gram, the Preceptorship Program, and will co- 
operate with the State Medical Association on 
physician placement when it involves alumni of 
the University of Missouri. Dr. Baker has already 
visited a great many of the local medical societies 
and will perform a key role in the exploration 
of possible cooperative endeavors between the 
School of Medicine and full time practitioners in 
the state. 

Gail Bank, a member of the Extension Divi- 
sion, has joined the staff on a full time basis as 
Executive Director of the Postgraduate Program. 
He is currently working on a Ph.D. degree from 
the University of Chicago in adult education, 
and his leadership is expected to provide a great 
deal of strength for the growing postgraduate 
program. 

Dr. Robert J. Jackson, Chairman of the De- 
partment of Pediatrics, has returned after a sab- 
batical leave in Lebanon, where he served as 
visiting professor at the American University at 
Beirut and was instrumental in setting up studies 
for the investigation of the nutritive value of 
human milk. 

It is impractical to attempt to fist by name 
all of the new persons who have joined the 
faculty, but many exceptional individuals have 
joined the staff during the last year. The evi- 
dence of the productiveness of the staff is quite 
clear through the several texts and a growing list 
of scientific publications which have appeared 
to their credit. All of the medical and surgical 
specialties are now represented on the faculty. 
The students and house staff are assured of the 
highest quality 7 in the teaching and patient care 
programs in which they participate. 

A number of full time positions have been 
filled at Kansas City General Hospital and Chil- 
dren’s Mercy Hospital during the last year. Dr. 
John Arnold has assumed the post as Head of 
the Department of Internal Medicine; Dr. James 
Elam heads the Department of Anesthesiology; 
Dr. Ned Smull is now Head of the Department 
of Pediatrics and Director of Children’s Mercy 
Hospital; Dr. Ide Smith is Head of Pediatric 
Surgery; and Dr. Charles Poser has accepted the 
post as Chief of the Section of Neurology to be 
effective July 1. These appointments carry regu- 
lar University status, and designate the first of 
the growing group of individuals who are dedi- 


276 


UNIVERSITY OF MISSOURI MEDICAL CENTER— WILSON 


Missouri Medicine 
April, 1964 


eating their efforts toward continuing the im- 
provement of the programs at Kansas City Gen- 
eral by bringing them into a status comparable 
with other teaching medical centers. Other full 
time staff have been added, but again for lack of 
space, only those who are in charge of programs 
have been mentioned. 

From the Ecology Field Station on the Colum- 
bia campus, Dr. James E. Banta has been called 
by the U. S. Public Health Service to serve as 
Deputy Medical Director of the Peace Corps. 
His replacement as chief of the Field Station will 
be Dr. Gerald H. Payne, a member of the Public 
Health Service who previously was an assistant 
professor of Preventive Medicine at the Uni- 
versity of Utah. He will begin his new duties in 
the near future. 

The Woodhaven Christian Home for Children, 
which has an affiliation with the University, is 
now in the process of adding staff and admitting 
patients. Dr. James M. Pickens from the faculty 
of the Department of Pediatrics has accepted the 
position as Medical Director, and Dr. Rodman 
P. Kabrick, clinical psychologist, has assumed 
the post of psychologist in the new institution. 
The affiliation between Woodhaven and the Uni- 
versity includes a number of the divisions of the 
University, and hopefully this will develop as an 
outstanding example of collaboration between 
disciplines for the benefit of exceptional children. 

General Perspectives of the 
Medical Center Program 

In an era when health and scientific informa- 
tion is increasing at an incredible rate, the most 
acute problem which faces practitioners and 
medical schools is the need for the development 
and use of new methods for the distribution of 
health care. To say it in another manner, al- 
though it is technically and potentially possible 
for an individual to receive much better health 
care now than he would have received even five 
years ago, the gap between that which might be 
given and that which is actually delivered is wid- 
ening rather than narrowing. In addition to the 
need for each of the clinical disciplines to study 
carefully its own role, it has become apparent to 
Schools of Medicine across the country that there 
must be developed a group of individuals in a 
discipline which would study this as a problem 
in itself. It was to this purpose that the previous 
Department of Preventive Medicine and Public 
Health of the University of Missouri School of 
Medicine was changed to the Department of 
Community Health and Medical Practice. Under 


the guidance and leadership of Dr. Carl J. Mar- 
ienfeld, who also serves as Medical Director for 
the Missouri State Crippled Children’s Service, 
there have been gathered an impressive group of 
faculty members in the fields of physical medi- 
cine, social work, sociology, anthropology, eco- 
nomics, epidemiology, statistics and administra- 
tion. In collaboration with the State Division of 
Health through their Program Development 
Unit, and in cooperation with a number of de- 
partments of the University, this group has 
moved steadily forward in the study of the prob- 
lem. While any single group will only be able to 
touch upon a few selected items, the type of 
momentum which has been developed and the 
general example of an approach to the problem 
should be of value to many other institutions. 

Affiliations .—The affiliations which have been 
formed by the School of Medicine with other 
institutions also reflect this concern with the 
complexities of modern health care. In each of 
the institutions with which an affiliation has been 
established, a different type of medical care 
program will be found and, thus, a different op- 
portunity is afforded to study technics for im- 
proving that type of care. This includes the new 
VA Hospital which will be built in Columbia in 
the near future. 

Present affiliations include Kansas City Gen- 
eral Hospital, Children’s Mercy Hospital in Kan- 
sas City, and the new Intensive Treatment Cen- 
ter in Kansas City; Ellis Fischel Hospital, Wood- 
haven Home and Boone County Hospital (for 
nursing) in Columbia and St. Luke’s Hospital in 
St. Louis. 

New Programs 

Mid-Missouri Mental Health Center .— The 
State Division of Mental Diseases will be letting 
contracts for the construction of a 120-bed Mid- 
Missouri Mental Health Center in Columbia 
sometime during the summer months. This will 
be a unit to provide intensive treatment for emo- 
tional disorders for patients of all ages and will 
have one ward dedicated to the problems of 
alcoholism. 

In this cooperative program, full medicolegal 
responsibility will be retained for the service 
portions of the program by the Division of 
Mental Diseases. The academic programs and 
research programs will be under the guidance 
and sponsorship of the University. The building 
itself will be attached to the present Medical 
Center complex so that patients may move 
freely from one portion of the building to an- 


Volume 61 
Number 4 


UNIVERSITY OF MISSOURI MEDICAL CENTER— WILSON 


277 


other. Duplication of services in the two institu- 
tions will be avoided whenever possible. Co- 
operative programs will include joint use of the 
kitchen, food service facilities, x-ray, central 
laboratory, pharmacy and other similar services. 
It is illustrative of the way in which needs of 
the patients can be met while at the same time 
the by-products of their care can be used to 
markedly increase educational opportunities for 
those people who will be providing such care in 
the future. This is particularly important in Mis- 
souri where there exists such a shortage of indi- 
viduals who have training in the mental health 
field. 

Veterans Administration Hospital— Present 
plans call for a 480 bed VA Hospital to be under 
construction in Columbia in 1965 and completed 
in 1967. The new facility, which will be connect- 
ed by an underground tunnel to the present 
Medical Center complex, will provide 240 beds 
for pychiatric and neurologic problems and 240 
beds for general medical and surgical care. This 
hospital will be under a Dean’s Committee ad- 
ministration, which means that the professional 
staff will be members of the Medical Center fac- 
ulty and that residents and students who are in 
training in the University will be able to receive 
a significant portion of their experience in this 
hospital as a part of the care program. This, 
again, epitomizes the wisdom of providing ser- 
vice to patients in an area where education can 
function as a by-product of such care, thus 
rendering the highest quality of medical care 
and, at the same time, providing a significant 
augmentation to the educational program with- 
out constructing additional facilities for that pur- 
pose. 

Computer Program— The computer program 
is mentioned here only for the sake of complete- 
ness. An article appears elsewhere in this issue 
describing the general nature and intent of this 
program. Suffice it to say that one of the great 
problems in the distribution of health care has 
been in the growing complexity, amounts and 
inter-relationships of the data related to health 
care. It has become almost impossible to keep 
an adequate medical history on a mobile popu- 
lation. It may well be that electronic data storage 
and transmission will provide this answer, among 
many others. The article by Dr. Lindberg gives 
further details. 

Construction— As was indicated in the last re- 
port, the Health Research Facilities Branch of 
the National Institutes of Health allotted $750,- 
000 to the University of Missouri School of Medi- 
cine in recognition of the strength of its research 


program and the need for additional space in 
which to pursue that program. The State Legis- 
lature in a forward looking manner appropriated 
the matching $750,000 and before this article 
goes to press, the new building should be under 
construction. This will provide an additional five 
stories for the connecting wing between the 
present hospital and the Medical Sciences Build- 
ing and an additional three stories on the west 
end of the present Medical Sciences Building. 
In addition, the University has been able to ob- 
tain funds from private sources to build three 
stories on the northern wing of the Medical Sci- 
ences Building which will be leased to the U. S. 
Public Health Service Ecology Field Station for 
their use, thus giving them more modern quar- 
ters and providing a closer relationship to the 
medical staff, which is important in their work. 

Projections for the Future— Because of inade- 
quate space for class rooms and faculty, it has 
been necessary this year to limit the number of 
students who could be accepted into the pro- 
gram of the School of Nursing. In a time when a 
great shortage of nurses exists, this seems a pe- 
culiar contradiction. In addition, the School of 
Medicine has had to limit its enrollment to 85, 
although clinical material is available to take 
classes of 100 or slightly more. As was mentioned 
previously, this limitation, too, is based upon lack 
of space for class rooms and space for faculty 
members. Also the present Outpatient Clinic 
facilities are completely inadequate to handle 
the volume of patients who are now coming, and 
expansion in this area is vital both for the benefit 
of services to the patient as well as for the edu- 
cational program. If companion facilities were 
available to expand the Outpatient Clinic and 
the present Medical Sciences Building, there is 
little doubt but that both the nursing and medi- 
cal school classes could be increased by as much 
as 20 to 25 per cent with only modest increase in 
operational costs. It is therefore the intent of 
the School of Medicine to seek out gift and grant 
sources which may be used to assist in this and 
to request from the coming legislature the match- 
ing money to allow this much needed growth. 

Major Problems.— The Medical Center has now 
been in operation for about eight years. Most of 
the original equipment in this building is still in 
use and one of the major problems now facing 
the Center is the replacement of obsolete and 
worn out equipment. The problem of obsoles- 
cence is easily understood if one recognizes that 
the amount of medical information available is 
doubling each 10 years. This means that the sup- 
porting diagnostic and therapeutic equipment 


278 


UNIVERSITY OF MISSOURI MEDICAL CENTER— WILSON 


Missouri Medicine 
April, 1964 


must be modified in accord with the new infor- 
mation. This is particularly true in radiology, 
but equally true in laboratories and other areas. 
If the Medical Center is to keep pace with the 
advancement in health care, the time has come 
when a significant portion of this equipment 
must be replaced because of obsolescence. An 
additional and substantial amount will need to 
be retired because it is now badly worn. A re- 
quest will be taken to the legislature for the first 
of several installments of funds for this purpose 
and it is hoped that the replacement process will 
be adopted on a regular basis, following a longi- 
tudinally developed plan. 

Although the majority of physicians in the 
state now understand the program of the Medi- 
cal Center and are quite supportive of the way 
in which it must operate in accepting patients 
and in handling the consultations which it 
renders, there are still enough members of the 
healing arts who do not understand to create 
some problems in communication. Booklets are 
being prepared, and a number of staff members 
are spending time in community meetings in an 
attempt to explain these practices so that it will 
be possible for any one who is interested to be 
informed and to understand the workings of the 
Medical Center. Only by using a selective refer- 
ral basis is it possible in a 441 bed hospital to 
accept and to teach the large number of stu- 
dents and men in residency training. The pres- 
ent arrangement provides a low tax cost and an 
extremely high educational result. It is hoped 
that this approach will be understood and con- 
tinually supported by practitioners and the pub- 
lic alike. It is believed that the University should 
serve as a consultation source but that continu- 
ing care must remain with the family physician 
and the community hospital. 

While the number of applicants to the Medi- 
cal School has increased considerably in the last 
two or three years, there is still a great need for 
support and assistance from alumni and from 
practitioners throughout the state. The future 
of the profession is entirely dependent upon the 
caliber of young men who can be attracted into 
it. In this instance, all members of the Medical 
Association are urged to help either this school, 
or the school of their choice, in recruiting quali- 
fied young men for the practice of medicine. 

Although the State Medical Association has 
temporarily met the immediate needs for loan 
funds for students, there still is much more to be 
done before there can exist within the State of 
Missouri a revolving fund of money large enough 


to meet all the needs for loans to medical stu- 
dents. Since once a fund is established it is 
completely self-supporting and since its estab- 
lishment would reduce, if not eliminate, the 
needs of dependence upon federal sources of 
support for this purpose, it is urged that every- 
one give serious thought to the ways in which 
they can help to increase support of the Missouri 
State Medical Foundation. 

Finally, the largest single investment which 
the state and the University have in the Medical 
Center is in its operating budget. Hopefully, in 
order to gain the most from these expenditures, 
construction money will be forthcoming in large 
enough amounts to permit the operational funds 
to be expended in the best possible manner. It 
is sobering to recognize that each two years sees 
an operational expenditure which is equivalent 
to the total cost of the Medical Center physical 
plant. Money wisely spent for expanded space 
and additional facilities will be compensated 
many times over by increased efficiency in the 
use of the personnel who work within those en- 
virons. Certainly, physical facilities which are 
adequate both in appointment and in size are a 
necessary ingredient if the taxpayer is to get 
full return. 

Summary 

In conclusion, this has been a rewarding four 
and one half years in which the warm support of 
many people and the intelligent and concerted 
activities of an enthusiastic faculty have pro- 
duced results which are almost unbelievable. 
The growth of the School of Medicine, both aca- 
demically and in scope of service, has far ex- 
ceeded the fondest hopes of even the most en- 
thusiastic supporters. This has been due largely 
to the understanding of the members of the prac- 
ticing profession throughout the state and citi- 
zens of the state at large. This growth and devel- 
opment can be furthered only if the School can 
continue to have the interest, the constructive 
criticism, the advice and the counsel of each of 
the individuals who has contact with it. Our 
pledge is never to forget that the only reason for 
the existence of a School of Medicine is to better 
the health of society at large, and to do this 
primarily through producing better practitioners 
and members of the healing arts profession. It 
is hoped that a close working relationship will 
continue to be built between those who bear 
prime responsibilities for health service in the 
communities and their School of Medicine in 
Columbia. 


WILLIAM D. MAYER, M.D., Columbia 


Development of a New Curriculum at the 
University of Missouri School of Medicine 


More than four years ago, in January 1960, the 
faculty of the University of Missouri School of 
Medicine began a broad review of its medical 
school curriculum. This review has resulted in 
significant changes in the curriculum which will 
be initiated in June and September, 1964. It is 
felt that the reading audience of Missouri Medi- 
cine might be interested in a summary of this 
new curriculum. 

The review of the curriculum began with a 
survey of the educational programs then in exist- 
ence in the medical schools in the United States. 
University of Missouri faculty members visited 
selected medical schools in order to gain first 
hand information of their educational programs. 
The reports of these visits were discussed at 
length by members of the Committee on Educa- 
tion. The Committee then drafted a set of prin- 
ciples and goals of medical education adapted to 
the needs of the State of Missouri and the char- 
acteristics of the University of Missouri School 
of Medicine. These goals were reported at some 
length in the April 1961 issue of Missouri Medi- 
cine by Dr. Gwilym S. Lodwick, the Associate 
Dean and Chairman of the Committee on Edu- 
cation. The Committee and the Executive Faculty 
of the School of Medicine then began the diffi- 
cult task of constructing a curriculum which 
would best meet these goals. 

In addition to the efforts of the Committee on 
Education and the Executive Faculty, further dis- 
cussion was engaged by other faculty members 
through their departments and through the 
medium of two conferences on medical educa- 
tion. The first of these conferences entitled, 'The 
Changing Character of Medical Education” was 
held in September 1962. Participating in this 
conference were several guest authorities as well 
as the entire faculty. The second conference held 
in September 1963, was entitled, “The Faculty 
Forum on the New Curriculum” and functioned 
as a sounding board for the ideas which had 
evolved in the intervening year. 

All of the discussions centered around the de- 
sire of the faculty to provide the student with an 
opportunity to acquire the fundamental knowl- 
edge and skills of medical science and practice 


while still providing him the freedom and flex- 
ibility necessary for his maximal individual de- 
velopment. In medicine, as in all educational sys- 
tems, it is obvious that the educational needs of 
each individual vary greatly depending upon the 
student’s native ability as well as his previous 
educational experiences and future goals. At the 


A review of the new curriculum at the 
University of Missouri School of Medicine 
is presented. 

Dr. Mayer is Assistant Dean, Assistant 
Professor of Pathology and Chairman of 
the Committee on Education of the Uni- 
versity. 


same time, a certain core of knowledge and 
skills should be acquired by each individual with 
the degree of Doctor of Medicine. What is need- 
ed is a curriculum which will permit the estab- 
lishment of this core within the framework of 
freedom for individual growth. 

First and Second Years 

The skeleton of the new curriculum is outlined 
in table 1. The first two years in the new curricu- 
lum have approximately 500 contact (lecture 
and laboratory) hours per semester. This repre- 
sents significant reduction in contact time and 
provides the student with the equivalent of two 
half days’ free time within a five and one half 
day week. The free time will be available to the 
student for additional course work, leisure or 
further effort on his medical course work. 

Into the first year curriculum have been added 
two courses which are currently not offered. The 
first of these is a course entitled “Correlation 
which will present clinical material that is par- 
ticularly pertinent to the basic science studies of 
a given week. The second is a course in “Human 
Ecology and Behavioral Science.” This course 
will provide the student with concepts of man 
built on his genetic, anthropologic, sociologic 
and psychologic backgrounds. Thus, early in his 


280 


DEVELOPMENT OF A NEW CURRICULUM— MAYER 


Missouri Medicine 
April, 1964 


TABLE 1 

NEW CURRICULUM 


First Year 


First Semester 
S eptember -January 

HOURS 


Anatomy 172 

Biochemistry 220 

Human Ecology and 
Behavioral Science 60 

Biophysics 48 

Correlation 12 


512 


Second Semester 
February-May 

HOURS 


Anatomy 348 

Physiology 92 

Human Ecology and 
Behavioral Science 60 

Correlation 12 


512 


Second Year 


First Semester 
September- J anuary 


Second Semester 
February-May 


HOURS 


Microbiology 192 

Pathology 128 

Physiology 96 

Introduction to 

Medicine 80 


496 


HOURS 

Pathology 256 

Pharmacology 144 

Introduction to 

Medicine 80 

Radiology 16 


496 


Third and Fourth Year 

This is a two year experience commencing in June 
following the completion of the second year and ending 
at graduation in June two years later. The two year 
period is divided into 10 nine week blocks and two 
seven week blocks. During the 12 blocks the student is 
required to take the following: 


1. Medicine 2 blocks 

2. Surgery 2 blocks 

3. Community Health-Preceptorship-Radiology 1 block 

4. Obstetrics-Gynecology 1 block 

5. Pediatrics 1 block 

6. Psychiatry 1 block 

7. Elective 1 block 

8. Free Time 3 blocks 


The elective block must be spent in an educational 
pursuit. Numerous opportunities are available to the 
student both within and without the Medical Center. 
The free time blocks may be spent by the student in any 
way he chooses. However, educational opportunities of 
great variety will be available to the individual if he 
chooses to use this free time in further educational 
experience. 


medical school training the student will be ex- 
posed to a broad picture of man and his environ- 
ment. 

In the second year, a course in “Introduction 
to Medicine” has been added. This will provide 


the student with his introduction to clinical 
medicine. It will replace individual courses cur- 
rently being offered in physical diagnosis and 
history taking, psychiatry, introduction to sur- 
gery, obstetrics and preventive medicine. By 
combining these courses, unnecessary duplica- 
tion of material will be removed and the stu- 
dents will have a unified primary contact with 
clinical medicine. It is expected that a single 
course on introduction to clinical medicine will 
also provide a better pedagogic approach. Fre- 
quently the student’s problem is not that he has 
too much to do, but that it is in too many differ- 
ent areas or directions. 

Third and Fourth Year 

The third and fourth year programs in the 
new curriculum represent a greater departure 
from programs existing elsewhere. One of the 
greatest concerns with the current third and 
fourth year was the lack of flexibility. It was 
felt that the clinical experience and responsibili- 
ties available to students was of a high quality. 
However, there is little opportunity for one 
student to vary his experience significantly from 
his peers. From the time our students commence 
their third year in September until they complete 
their fourth year some twenty-one months later, 
they have only six weeks of elective opportunity. 

Ways were sought by which the individual 
student’s third and fourth year curriculum might 
be modified to suit his own individual needs and 
not appreciably interfere with his core clinical 
experience. It was decided that by incorporating 
the vacation time normally present in the sum- 
mer between the second and third year (stu- 
dents currently have no summer vacation be- 
tween the third and fourth years ) the time might 
be more usable to the student. Out of this con- 
cept came the two year block experience out- 
lined in table 1. 

In the new third and fourth year curriculum, 
the student will have a maximum of 36 weeks in 
which he can seek additional experiences in clin- 
ical medicine, research and other educational op- 
portunities. The student will be required to 
spend nine weeks of this time in educational pur- 
suit while 27 weeks will be totally at the discre- 
tion of the student, that is, free time. 

In a survey of the current second year class, 
who will be participating in the new program 
during the coming year, it was indicated that 
approximately one third of their free time will 
be spent in elective type endeavors within the 
Medical Center. Needless to say, it is encourag- 


Volume 61 
Number 4 


DEVELOPMENT OF A NEW CURRICULUM— MAYER 


281 


ing to note that the students voluntarily are will- 
ing to give up vacation time in this proportion to 
spend it with their faculty. Approximately an 
additional one third of the free time will be 
spent in medical or paramedical pursuits outside 
the Medical Center, while the remaining one 
third will be used on vacation or in nonmedical 
positions for gainful employment. Already some 
of the students are planning on extended educa- 
tional experiences in other Medical Centers in 
this country and abroad. Some are looking for- 
ward to working on Master’s degrees in scientific 
areas. 

Another innovation in the final two years is 
the Community Health-Preceptorship-Radiology 
block. During four weeks of this block, the stu- 
dent will function in a preceptorship with a 
practicing physician in a relatively small com- 
munity in the state. This is an expansion of the 
preceptorial program already underway in the 
curriculum. It was felt that all students should 
have an opportunity to participate in the prac- 
tice of medicine in a setting other than the Uni- 
versity Medical Center. The preceptorship block 
provides this opportunity. 

Also incorporated into the new curriculum will 
be a set of lectures and conferences. There will 
be daily one hour noon lectures for third and 
fourth year students on Monday, Tuesday and 
Wednesday of each week. There will thus be a 
sequence of 300 hours of lecture material in the 
clinical sciences provided on a two year basis. 

Saturday mornings, from 10:00 a.m. to 12:00 
noon, will be devoted to a set of four conferences 
that will be rotational. One week will be devoted 
to an expanded C.P.C.; the second to a thera- 
peutic conference; the third to a correlative 
clinic and the fourth to a clinical-basic science 


conference. It is anticipated that these programs 
will be attended not only by the third and fourth 
year students, but the faculty and house staff as 
well. This time has also been made available to 
the first and second year students to attend as 
seem appropriate. In addition, it is hoped that 
physicians and faculty outside of the Medical 
Center will feel free to attend and participate 
in these weekly conferences. 

Comments 

An interesting by-product of the discussions 
of the curriculum, by faculty and students alike, 
has been the increased attention of all to the 
educational process. Concomitant with the dis- 
cussions, intra-departmental changes have oc- 
curred in the teaching of courses which have im- 
proved them within the current curricular frame- 
work. These advances will of course, carry over 
into the new curriculum. 

Summary 

A brief review of the new curriculum of the 
University of Missouri School of Medicine has 
been presented. It is believed the proposed cur- 
riculum presents the student with the oppor- 
tunity of acquiring the necessary core knowl- 
edge and skills of the Doctor of Medicine while 
maintaining sufficient flexibility to permit maxi- 
mal development of individual talents and abili- 
ties. 

It is realized that the essence of any learning 
situation is in the exchange of ideas between in- 
telligent, well motivated students and dedicated, 
knowledgeable faculty members. It is anticipated 
that the new curriculum will constitute a catalyst 
for this reaction. 


DONALD A. B. LINDBERG, M.D., Columbia 


A Computer in Medicine 


It well be my purpose in this article to report 
on the program surrounding the installation of 
an IBM 1410 electronic digital computer at the 
University of Missouri Medical Center. To do 
this it will be necessary to discuss computing 
machines and medical education in a general 
manner. 

First, one should realize that if this article 


The installation of a 1410 computer fa- 
cility at the University of Missouri Medical 
Center is discussed. 

Dr. Lindberg is Assistant Professor of 
Pathology and Director of the Medical Cen- 
ter Computer Program. 

This program is supported in part by the 
U. S. Public Health Service grants 5-T1-GM 
520-03, T2-CA 5063-10 and 1-SO1-FR-05387- 
01 . 


were to appear in a journal of physics, engineer- 
ing, mathematics, statistics or many chemical 
publications, no preamble or justification for a 
discussion of computers would be required. Like- 
wise, accountants, bankers, wholesalers, missile- 
men and a variety of new frontiersmen have 
many years ago come to grips with computer 
technology. It was not so many years ago when 
medicine was the most exciting new frontier. 
Medicine is not accustomed to being found in 
the rear ranks of those following after a scientific 
breakthrough. Yet in the field of modern com- 
munications and data processing technics medi- 
cine has truly missed an opportunity in not in- 
vestigating the contribution of this powerful new 
technology. 

The aim of the Medical Center Computer 
Program is to do just this, to investigate the 
proper role of a modern electronic digital com- 
puter in the practice and teaching of medicine. 
In truth, it is not now known what the role 
should be. There are many projects which are 
being actively pursued— many more than can be 
presented in detail— but one cannot say which is 
the really important one. The one, that is, which 
will take the teaching of medicine out of the 


realm of pedagogy into that of graduate educa- 
tion, or the one which will improve the diag- 
nostic approach to a patient, or the as yet un- 
developed technic which will make the medical 
literature and patient care data of our burgeon- 
ing medical record rooms a living record which 
can offer daily teaching to us as students and 
practitioners. It is not even known that one of 
these great discoveries is actually included in the 
initial projects. One tiling known, however, is the 
expertise of the accountants and missile builders 
with these computing machines will never re- 
sult in a ready made system for the practice or 
teaching of medicine. That will only be done by 
physicians. 

Laboratory Data 
Transmission and Retrieval 

A major initial project is the development of 
a system for reporting all clinical laboratory de- 
terminations through the computer. “Through” 
is the important part of this concept. At this 
moment the determinations from the clinical 
bacteriology, serology and chemistry laboratories 
are transmitted to the ward by a preliminary sys- 
tem based on an IBM-1912 Card Reader and 
Teletype Corporation transmitting equipment. 
This is important because it means that this 
data is already in a physical form, i.e., punched 
cards, which makes it immediately available for 


Fig. 1. 1410 Computer Facility at the University of 
Missouri Medical Center. 



282 


Volume 61 
Number 4 


A COMPUTER IN MEDICINE— LINDBERG 


283 


computer examination. In the new system being 
developed the data will pass through the com- 
puter before being transmitted. This means that 
the computer can be programmed to examine 
the data and to weed out errors of clerical or 
laboratory technic, inverted patient unit num- 
bers, mis-addressed reports, or errors in calcula- 
tion, to evaluate it from the vantage point of up- 
to-the-minute quality controls, to compare the 
result with previously recorded results on that 
same patient which have been retained in mem- 
ory, and in short to bring into consideration the 
multitude of factors which are almost beyond 
the patience of a human being. The computer 
cannot exercise medical judgment. We will be 
content initially if it merely manages to accurate- 
ly collect, route and record the data. In return 
for this we may gradually give it more important 
tasks. 

Initially its major contribution will be in mak- 
ing rapidly available the past data of the hos- 
pital laboratories. Approximately 500,000 deter- 
minations per year are performed here; so that 
each attempt at review of the records has in the 
past been a research effort in itself. This particu- 
lar task is something well within the capability 
of a computer system. No technological break- 
through is necessary in order for a modern com- 
puter to sort through two or three million labora- 
tory determinations. It is only necessary to do 
the initial work which provides these data in 
computer accessible form. 

This approach to data processing requires 
some elaboration. 

Data Retrieval 

While there are some reasonably complex 
arithmetical calculations in medicine, these are 
not prominent in the practice of the art. One 
seldom even sees a second decimal place in a 
hospital. Medicine needs computers because 
such systems can function as rapid data process- 
ing and retrieval devices, not because of the 
computations required. There is, of course, also 
the minority view that inadequate mathematical 
training automatically limits the potential use of 
mathematics. See various lay press articles. 1, 2 
Whether or not there are fertile unexplored 
mathematical valleys in medicine, there are cer- 
tainly many well known unexamined mounds of 
patient care data in the medical record rooms. 
These are the objects of the initial treasure hunt. 

Data which has been coded and written to 
magnetic tape can be read in sequential fashion 
at 20,000 characters per second. Data written to 



Fig. 2. Another view of the computer. 


magnetic disc storage can be read in totally 
random fashion at 9,000 characters per second. 
Magnetic tape drives (although not as fast as 
those mentioned) and a 1301 Random Access 
Disc File are part of our computer installation. 
Along with this input-output oriented computer 
system is a 1403 high speed printer ( 800 printed 
lines per minute). 

With these devices it is planned to record 
as much as possible of the significant medical 
record on tape and to retrieve and rework the 
data by use of the computer. 

Other Specific Projects 

Examples of specific files of patient material 
which are being processed include the tumor 
registry, the hospital discharge diagnosis and 
operations file and the surgical pathology file. 
Scheduled for subsequent processing are the 
radiology diagnostic file and the coded records 
of the interpretation of the Heart Station electro- 
cardiographs. It should be noted that it is pos- 
sible to process such data only because the phy- 
sicians responsible for these service areas have 
taken pains to code and preserve their own valu- 
able data in the years past before a computer 
was readily available to process it. 

The areas of the significant medical record 
which yield themselves least readily to electronic 
data processing are the interrogative medical 
history and the physical examination. Here no 
suitable codings or classifications exist. The 
data are largely prose and as such are difficult 
to deal with in a computer. Once coded, how- 
ever, these too are easily processed; so in the be- 
ginning it will be necessary to create a coding 
system. The task has been initiated for the oph- 




284 


A COMPUTER IN MEDICINE— LINDBERG 


Missouri Medicine 
April, 1964 


thalmology-otolaryngology clinic at the Medical 
Center. Plans are also being formulated for en- 
coding and processing interrogative medical his- 
tory and physical examination data from a spe- 
cial medical clinic at the Kansas City General 
Hospital. 

This brief list does not include all of the sep- 
arate files available but includes the initial work. 
In addition there are about 40 research projects 
which relate to the work of individual investi- 
gators and a number of hospital administrative 
tasks which are being performed. These two 
categories of computer jobs include some inter- 
esting pieces of work but do not necessarily relate 
to the prime objective of the moment, which is 
the encompassing of patient care data. 

Computer in Medical Teaching 

So many judgments about patients and medi- 
cal problems hinge on a statistical sort of evalu- 
ation that it has seemed reasonable to begin to 
introduce these technics in the teaching situa- 
tion. At least, a computer system offers a medical 
student or physician a means of rapidly search- 
ing large numbers of hospital records. This abil- 
ity can supplement or replace the role of a 
teacher in “telling” the student what diagnoses 
are likely or rare. The student can draw his own 
conclusions from the facts of hospital experience. 
For example, it will be no news to the reader 
that a patient with fluffy peripheral and mid- 
field pulmonary infiltrates who resides in Mis- 
souri has a likelihood of having histoplasmosis 
which is grossly different from that of a similar 
patient who resides in Boston, Mass. How differ- 
ent the chances really are is something no one 
can say at present. With proper handling of data 
we hope to be able to make statistical statements 
about this sort of question following processing 
of the patient data. 

Another example of a question which arises in 
student teaching groups concerns the antibiotic 
sensitivity pattern of microorganisms. “Has there 
been an increase in the number of penicillin re- 
sistant Staphylococcus aureus isolates in this hos- 
pital in the past four or five years?” It is now 
possible to give an exact report on the isolation 
and antibiotic susceptibility pattern of this or- 
ganism in the period during which teletype 
transmission of results has been in use. The old 
records are being encoded manually. The cur- 


rent reports automatically become incorporated 
in the computer system. 

Another facet of the teaching program is the 
use of the computer as a case retrieval device. 
As the number of cases in a hospital builds up, 
the use of simple tabulator card processing de- 
vices to search the diagnosis file, even to recover 
only the unit numbers of patients, becomes in- 
creasingly difficult. To request the unit numbers 
of individuals who “have diagnoses A, B and C, 
who were seen in 1961, and came from counties 
1, 2 or 3” becomes almost impossible without a 
computer system. Fortunately one of the staff 
physicians has asked this sort of question re- 
cently and we now know that it is relatively 
easily answered with the new computer system. 

The Physician and Data Processing 

Something should be said of the reaction of 
the faculty and staff of the School of Medicine 
to the arrival of a large computing device. Phy- 
sicians seem to enjoy picturing themselves as 
hopeless disorganized, harried, muddlers- 
through-life who would be totally lost without 
the combined assistance of at least a wife, a sec- 
retary and nurse. Consequently, to be openly 
grateful for a neat, clean, orderly computer 
would run counter to the physician’s self image. 
Fortunately, there are inaccuracies in this de- 
scription. First, computer operations are neat, 
clean and orderly only when viewed from a dis- 
tance. And second, most good physicians are ac- 
tually compulsively good record keepers and are 
furthermore devoted to their own data and pa- 
tients. Thus, a surprising number of friendly col- 
leagues have suddenly produced quantities of 
carefully kept accurate data for computer proc- 
essing in the new facility. 

Based on the first three months’ experience, I 
predict the development of a romance between 
physicians and computers which will rival that 
seen with stethescopes and electrocardiographs. 
It will be a great but pleasant challenge to see 
that this latest affair of the heart makes a signifi- 
cant contribution to medical knowledge and wis- 
dom. 

Bibliography 

1. Inside numbers. Time Magazine. Education Section. Jan. 
31, 1964. 

2. The Analytical Engine, The New Yorker Magazine. Oct. 
21 and Oct. 26, 1963. 


G. R. RIDINGS, M.D., Columbia 


Irradiation in the Management 
Of Peptic Ulcer 


The radiation therapist is so much a full time 
oncologist that it is easy to forget that irradiation 
is, at times, useful in disorders other than cancer. 
One of these is peptic ulcer. 

Even though irradiation has been used in 
treatment of peptic ulcer for more than 45 
years 1-4 its use has, mainly, been limited to a 
few isolated areas. Since the first blush of en- 
thusiasm for gastric freezing is now fading due 
to its hazards, 5 this is perhaps an appropriate 
time to be reminded of the older technic— radia- 
tion. 

Irradiation effects on the stomach were recog- 
nized early and were shown in experimental 
work. 6, 8 Subsequent investigators 8-12 have ex- 
plored this in further detail. In summary, the gas- 
tric mucosa is more sensitive to irradiation than 
is the skin; other parts of the stomach are un- 
affected except by high doses of irradiation. The 
histologic changes occur mainly in the peptic 
glands, less in the mucous glands. The pepsin- 
producing chief cells appear to be somewhat 
more sensitive than the acid-producing parietal 
cells. About one week following irradiation the 
first histologic changes appear: asymptomatic 
hyperemia, edema and exudation. In the gland 
tubules the earliest changes are in the depths of 
the glands with destruction of the chief and pari- 
etal cells, while the more resistant mucous cells 
of the gland neck remain, creating deep, bottle- 
shaped pits. In healing, there is downward pro- 
liferation of the neck cells, reconstituting the 
gland lining. 

Functional changes may occur even before his- 
tologic lesions appear and, after 10 to 14 days, 
free acid may disappear and pepsin be consider- 
ably reduced. There may be permanent achlor- 
hydria or reduced acid secretion. Clinically, the 
reduction of gastric acidity after irradiation is 
variable and unpredictable, even though there 
have been attempts to evolve parameters which 
would allow prediction. 13 

Clinical 

Carpender and associates 14 analyzed 116 pa- 
tients with gastric ulcer and 113 with duodenal 


ulcer, all with recurrent or persistent disease in 
the face of a medical regimen, followed five to 
10 years. Most were given 1600 to 1700 r to the 
stomach in 10 days, along with continuation of 
their medical regimen. Of those with gastric ul- 
cer, 53 per cent healed and remained so, healed 
but recurred in 40 per cent and persisted after 
irradiation in 6.7 per cent. Of those with duo- 
denal ulcer 66 per cent were free of recurrences, 
16 per cent were eventually subjected to surgery. 

Palmer, et al., 15 ’ 16 in 723 patients, felt that the 
recurrence rate, as computed “per 100 patient 


Irradiation in the patient with peptic dis- 
ease is discussed and it is pointed out that 
many patients can be benefitted when other 
forms of treatment have failed. 

Dr. Ridings is Professor of Radiology, 
University of Missouri Medical Center. 


years” dropped from 102 before irradiation to 17 
after irradiation (medical regimen continued), 
a reduction of 83 per cent; also, that there was 
a reduction of severity of recurrent symptoms 
and of serious complications. They concluded 
that irradiation was a safe and valuable adjuvant. 

G. Brown, 17 in a series of 81 patients, 44 with 
antroduodenectomy and gastroduodenal anasto- 
mosis followed in two months by 2000 r in three 
weeks, felt that postoperative irradiation im- 
proved results. 

Kieffer, et al., 18 in 23 patients with recurrent 
stomal ulcer following a Billroth II procedure, 
found that irradiation with 1800 r made it pos- 
sible to bring many of these patients under medi- 
cal management. They found that achlorhydria 
or marked hypochlorhydria lasting up to two 
years after irradiation was achieved in more than 
50 per cent of these patients. Because this state 
may not be permanent and because recurrence 
of symptoms is preceded by rise in free acid, it 
is wise to follow the acid secretion with serial 
tests. If recurrence occurs it is feasible to retreat 
one or two times at intervals as close as six 


285 


UMMC PATIENTS WITH PEPTIC ULCERATION TREATED BY IRRADIATION 


286 


IRRADIATION IN PEPTIC ULCER— RIDINGS 


Missouri Medicine 
April, 1964 


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Volume 61 
Number 4 


IRRADIATION IN PEPTIC ULCER-RIDINGS 


287 


months. There is evidence that if achlorhydria 
persists for more than three years no further ul- 
ceration need be expected. 

These findings are, in the main, confirmed by 
others. 11, 13, 14, 16 Carpender, et al. 14 found that 
temporary achlorhydria was produced in 41 of 
113 patients with gastric ulcer (previously un- 
controlled ) , with complete healing in 40 of these, 
the healing persisting during the period of 
achlorhydria. In nine of these patients the achlor- 
hydria persisted for one and one-half to 13 years, 
with no recurrences. In 24 patients persistent par- 
tial reduction of acidity was achieved; of these, 
only five had recurrence of ulceration. Patients 
in this series with duodenal ulceration showed a 
lesser degree of reduction of free acid, but a 
greater incidence of prolonged healing. The 
reason for this difference is not known. 

C. H. Brown, et al. 19 found that, of 121 pa- 
tients treated for complications of peptic ulcera- 
tion, there was in 90 per cent more than 50 per 
cent decrease in acid production; in 63 per cent 
this persisted through the sixth month. They ob- 
tained a good response without ulceration in 
72 per cent, questionable recurrence in 11 per 
cent and definite recurrence in 17 per cent. 

At the University of Missouri Medical Center 
10 patients have received irradiation in the 
course of their management for peptic ulcer. 
Eight are shown in table 1. Two are not in- 
cluded. One was unable to cooperate, even to 
lie still for a part of a minute; in the other, ir- 
radiation was attempted at a time after he had 
perforated, had massive bleeding, had surgical 
resection, had ruptured abdominal wall and 
bowel sutures, was bleeding, and had gross peri- 
tonitis and was preterminal. 

All eight cases were considered as unsuitable 
for surgery because of conditions other than gas- 
trointestinal. Most were quite old. All had severe 
peptic disease, most of long duration. All were 
kept on a medical regimen. The results in this 
group are favorable, even though these patients 
were not followed in a clinic in which this was a 
project, nor were they seen by people with great 
enthusiasm for this form of treatment. (Thus, an 
important element in this disease, psychotherapy, 
was missing insofar as irradiation results are con- 
cerned. ) 

The combination of any two technics, such as 
irradiation and a medical regimen, makes it diffi- 
cult or impossible to evaluate them separately. 
Klein, et al. 2 treated 50 patients who could not 
be controlled on a medical regimen, many with 
complications. This was done with irradiation 
alone, off all medications and on a free diet, giv- 


ing 1700 to 2000 r to the stomach in two to three 
weeks. The results were: 54 per cent excellent 
(symptom-free), 22 per cent fair (symptom-free 
except for short sporadic episodes of gastric dis- 
tress), fair (symptoms better but not symptom- 
free), and 22 per cent failures (no relief). Of 
the 11 failures, six eventually had gastric resec- 
tion; the other five were able to avoid surgery. 
Thus, of these cases which were failures under 
medical management and with complications, 
treated by irradiation alone, 71 per cent were 
cured of ulcerative disease and 88 per cent es- 
caped the necessity of surgery. 

Radiation Hazard 

The question of hazards of irradiation has been 
discussed. 14 ’ 16 There is occasional mild anorexia. 
In earlier years there was usually mild erythema 
of the skin in the irradiated field, occasionally 
some skin atrophy; with supervoltage these ef- 
fects are entirely eliminated. There has not oc- 
curred any case of neoplasia or blood dyscrasia 
attributable to the irradiation. There is no real 
genetic hazard; practically all of these treated 
people w^ere past the fifth decade of life; even 
those younger were in poor physical condition. 
In those cases wTuch do come to surgery, these 
doses of irradiation have not created complica- 
tions. 14 - 16 - 19 ’ 20 ’ 21 

Discussion 

So, it appears reasonable to conclude that ir- 
radiation is capable of reducing or eliminating 
the free acid of the stomach in a considerable 
proportion of cases; that there is a parallel be- 
tween the depression of the free acid and the 
clinical response; that, even in these patients 
selected because of failure of other forms of 
management, there is a gritifying response in 
many; and, finally, that this is a safe and rela- 
tively atraumatic form of treatment. 

What role, then should irradiation play in the 
management of peptic ulcer? Most workers agree 
there is a gratifying response in that it is best to 
use it in combination with medical management. 
Most seem to agree with these indications: (a) 
lack of control of disease following surgery; ( b ) 
failure on a medical regimen in a poor surgical- 
risk patient; ( c ) inability or unwillingness to ad- 
here to other management. There is, however, 
not agreement on whether irradiation should be 
utilized prior to surgery. One should consider 
these aspects: (a) irradiation of this type is safe 
and atraumatic; gastric surgery is always a major 
procedure; (b) irradiation gives dramatic relief 
(Continued on page 300) 


WILLIAM V. MILLER, Columbia 


Chromosomes and Human Disease 


The advent of antibiotics and tissue culture tech- 
nics has made it possible to investigate a whole 
group of poorly understood disease entities. 
Bertram and Barr’s 1949 1 discovery of the sex 
chromatin body also proved a useful tool for an 
understanding of sex chromosomal abnormalities. 
In 1956 Tjio and Levan 2 used these technics to 
revise the diploid human chromosomal comple- 
ment to 46 from 48, a figure which had been ac- 
cepted for more than half a century. Lejeune’s 2 
discovery in 1959 of a constant chromosomal ab- 
normality in Mongolism demonstrated that chro- 
mosomal abnormalities were not necessarily le- 
thal. 

All human cells normally contain the same 
number of chromosomes and genes— regardless 
of tissue— but the chromosomes per se are dis- 
tinguishable only during cell division. An excep- 
tion to this rule may be the Barr sex chromatin 
body (figure 1) which is thought to represent 



Fig. 1. Epithelial cells from a female (left) have a 
plano-convex pyknotic fragment on the nuclear mem- 
brane known as the Barr sex chromatin body. Cells from 
normal males ( right ) lack these bodies. 

part of one of the X chromosomes. 4, 5 In order 
to study human chromosomes blood is drawn in 
heparin, and the white cell-rich plasma is incu- 
bated in culture media for three days and al- 
lowed to grow. Colchicine is added (to stop 
spindle fiber formation) and the cells are incu- 
bated six more hours. The cells, many stopped in 
mitosis at metaphase, are washed and then 
placed in hypotonic solution to spread the chro- 
mosomes. They are then fixed and stained for 
microscopic and photographic analysis. 


The chromosomes are arranged in descending 
order of size and grouped by centromere loca- 
tion. 6 Most have median or submedian centro- 
meres, but a few have terminal centromeres 
( acrocentrics ) ( figure 2 ) . These acrocentric 


Laboratory technics are outlined and sug- 
gested etiologies and mechanisms of chro- 
mosomal defects are discussed. 

Mr. Miller is a Post Sophomore Student 
Fellow in the Department of Pathology un- 
der Pathology Training Grant 2G 520. 


chromosomes are associated with the nucleolus 
and are subject to considerable mechanical 
stress. 7 This relationship may account for the 
fact that anomalies of the acrocentrics are more 
common than those of the median and sub- 
median chromosomes. 8 

Etiology of Chromosome Aberrations 

Environmental factors are apparently responsi- 
ble for many of the defects seen in the chromo- 
somes. Experimental evidence indicates that ir- 
radiation with various high energy beams pro- 
duces significant defects, not only at the gene 
level but at the gross chromosome level as well. 
Chronic disease of many types is associated with 
chromosome anomalies, and mutagenic viruses 
have been postulated but never demonstrated. 9 
These, as well as other factors, may act by pro- 
ducing mutations in a genetic locus which con- 
trols normal cell division. The association of 
chromosome defects with increasing maternal 
age is well known, and it may be that increasing 
exposure to mutagenic agents accounts for this 
phenomenon. It is, however, difficult to account 
for the absence of similar findings in males. 

Mechanisms of Chromosome Anomalies 

Cell division is a complicated maneuver nor- 
mally resulting in daughter cells of identical 
constituency. Mitosis consists of five phases be- 
ginning in interphase, during which replication 
of the DNA helix occurs. During prophase, lysis 
of the nuclear membrane begins, the two cen- 



Volume 61 
Number 4 


CHROMOSOMES AND HUMAN DISEASE— MILLER 


289 



Fig. 2. Diagrammatic representation of submedian 
(left) and acrocentric (right) chromosomes as they 
appear in chromosome preparations. 


trioles migrate toward the poles, and the double 
strands of chromatin united at the centromere 
appear as chromosomes. In metaphase the DNA 
helix contracts and the chromosomes assume the 
“X” or “wishbone” shape seen in karyotypes. The 
chromosomes migrate toward an “equatorial disc” 
in the center of the cell and the spindle apparat- 
us forms, connecting centromere to centriole. 
It is here that colchicine acts to stop mitosis by 
preventing spindle fiber formation. During ana- 
phase the centromeres are split and chromatids 
migrate toward the poles through shortening of 
the fibers of the spindle apparatus. Reconstitu- 
tion of the nuclear membrane and complete cell 
division occur in telophase. The process of chro- 
mosomal splitting and migration toward poles is 
called disjunction. Errors of disjunction (non- 
disjunction) in which the chromatids are un- 
equally distributed account for most abnormal- 
ities of chromosome number (aneuploidy) (fig- 
ure 3). Mitotic non-disjunction produces chro- 



METAPHASE ANAPHASE 



TELOPHASE 


Fig. 3. Nondisjunctional cell division results in un- 
equal distribution of chromatids to daughter cells. 


mosomal mosaicism, in which some of the body’s 
cells may have abnormal chromosomal distribu- 
tion while others do not. 

Meiosis is a specialized form of cell division 
which accounts for the reduction of chromosome 
number from diploid (2n = 46) to the haploid 
(n = 23) distribution seen in germ cells. Meiosis 
differs from mitosis in several aspects: 8 (1) the 
DNA helix is reduplicated only once although 
two cell divisions occur, (2) chromosomes are 


arranged in homologous pairs at the equatorial 
plate (synapsis), (3) there is exchange of genet- 
ic information (crossing-over) between homol- 
ogous chromosome pairs at points of contact. 
Meiotic division involves two successive divi- 
sions, the first of which (reductional division) 
produces two haploid daughter cells. The second 
division ( equational ) separates the chromosomes 
at their centromere producing a second genera- 
tion of haploid daughter cells. In both of the 
meiotic divisions there are five phases similar to 
mitosis. Meiotic disjunction occurs twice, of 
course, first with the separation of the chromo- 
some pairs in anaphase I, and later in anaphase 
II. Meiotic disjunction is prone to many acci- 
dents of which non-disjunction is probably the 
most common. Apparently most structural anom- 
alies of chromosomes arise in meiotic gameto- 
genesis since structural anomalies affecting all of 
the body’s cells are clinically much more com- 
mon than structurally anomalous mosaic. 

Translocation occurs when two chromatids on 
separate chromosomes are fractured and the re- 
sulting fragments reunite with the “wrong” 
chromosome, that is, neither the original nor the 
homologous chromosome. Chromosomes bearing 
translocated fragments undergo mitotic and mei- 
otic non-disjunction in the usual manner and can 
be transmitted to offspring. Fertilization of a 
gamete with a translocated chromosome makes 
the zygote effectively trisomic for the genes 
present on the translocated fragment ( see figure 

4 )- 

If one of the fragmented chromatids at- 
taches to the chromosome that already carries 
the same loci that are present in the fragment, 
then one or several loci are duplicated within 
the same chromosome. Fertilization of the germ 
cell with duplicated loci produces a zygote 
which is functionally trisomic for the affected 
genes. This process of translocation of a fragment 
to its homogenous chromatid is called “duplica- 
tion” and the resultant gamete is said to be 
“partially trisomic.” 

Deletion, inversion and isochromosome forma- 
tion are rare cytogenetic mechanisms which have 
seldom been implicated in man. Deletions is the 
result of fracture of a chromatid with failure to 
reunite. Inversion occurs when a fractured chro- 
matid with failure to reunite. Inversion occurs 
when a fractured chromatid becomes reattached 
to the point of fracture but upside down to its 
point of origin. Isochromosomes are chromo- 
somes in which the genetic information on both 
sides of the centromere is identical. 


290 


CHROMOSOMES AND HUMAN DISEASE— MILLER 


Missouri Medicine 
April, 1964 


Clinical Manifestations of 
Chromosome Abnormalities 

Mongolism (Downs Syndrome ).— Although it 
had been suspected for some time that mongo- 
lism might be due to a chromosome anomaly, it 
was not until 1959 that Lejeune 3 demonstrated 
trisomy of the chromosome pair numbered 21 
(figure 4). Since that time Mongoloid children 



I ) Chromosome 21 is broken. 
Port ottoches to 15 



2) The intoct chromosome 21 moy 
be distributed to the gametes 
with either the normol 15 or 
the translocated 15. 





Early meiosls in a 
"carrier." Same os 
No. 2 above. 

Fig. 4. Familial mongolism is often due to chromo- 
somal translocation of part of chromosome-21 to chro- 
mosome-12. Segregation of chromosomes during germ 
cell production is shown here accounting for the high 
frequency of mongoloid children of “carrier” mothers. 



have been reported with translocation, inversion 
and mosaicism, as well as trisomy. A frequent 
disorder occurring at least once in 600 births, 
its clinical manifestations are well known. Often 
associated are severe mental retardation, mul- 
tiple skeletal anomalies and atrial septal defect. 

It is well known that there is an increased in- 
cidence of leukemia in Mongoloid children. In 
general, cytogenetic findings in tumors have 
been extremely variable— some tumors entirely 
normal, some with triploid and tetraploid cells. 
Certain forms of leukemia, however, have a rel- 
atively constant abnormal chromosome called 
the Philadelphia (Ph 1 ) chromosome which may 
represent a fragment of chromosome-21, pro- 


duced either by deletion or translocation of part 
of the long arms. 11 It is postulated that a leuko- 
poietic locus exists on chromosome-21, the du- 
plication of which (trisomy) produces acute 
leukemia and the deletion of which (Ph 1 chro- 
mosome) produces chronic myelogenous leuke- 
mia. 8 

Klinefelter’s Syndrome .— Also relatively com- 
mon, Klinefelter’s syndrome is associated with 
a 44 normal autosomes (non-sex chromosome) 
but an XXY sex chromosome distribution. The 
patients have small testes, aspermia, as well as 
a host of other features such as gynecomastia and 
long limbs. The extra X chromosome is apparent- 
ly partially “inactivated” 4 - 5 and appears on the 
nuclear membrane in buccal smears, producing a 
chromatin positive (female) pattern. 

Turners Syndrome .— Women with ovarian dys- 
genesis, short stature and associated anomalies 
fit clinically into the Turner’s syndrome. Other 
findings frequently include “webbed” neck, geni- 
tal infantilism, occasional coarctation of the aorta 
and scanty pubic and axillary hair. 9 The buccal 
smear is chromatin negative, compatible with 
the cytogenetic findings of 44A-X0. 10 Just as it 
is unclear how a chromosomal trisomy with its 
triple dose of genes is expressed as an anomaly, 
the mechanism by which chromosomal monoso- 
my affects the individual is not known. It is pos- 
sible that the absence of a second X chromosome 
allows all the recessive genes present on the re- 
maining X to be expressed. Mosaicism is rela- 
tively common in the Turner’s syndrome (20 
per cent ) ( figure 5 ) . 

Triple-X .— The XXX pattern is associated with 
a doubly positive buccal smear, but a variety 7 of 
phenotypes are seen. 12 These women are often 
apparently normal, but a somewhat higher inci- 
dence of mental retardation is reported. Al- 
though sterility and amenorrhea are occasionally 
present, they are by no means constant. The 
syndrome is not exceptionally common, the inci- 
dence estimated at about 1 : 1000. 

Group D-Trisomy.—A number of cases of tri- 
somy of one of the members of Group D ( 13, 14 
or 15) have been seen in this hospital and others. 
Since it is difficult to distinguish one chromo- 
some from another in this group, no attempt is 
made to number the chromosomes involved. 
These children are often grossly malformed and 
their prognosis is poor. 13 The incidence is low, 
and the sex ratio favors females slightly. The 
primary feature of the syndrome is maldevelop- 
ment of the central nervous system and associ- 
ated structures. In addition to faulty 7 develop- 




Volume 61 
Number 4 


CHROMOSOMES AND HUMAN DISEASE— MILLER 


291 


U H 8 " 

Group S-3 <A> 

Large vith ®edl»a 

ah U 

Group 6-5 fS) 

Large chro*»*c«** with eu^oed! 
cearrosstre*. 4 i» slightly longer. 

M n n m 

U U is n 

<C) OuJLam 

Medi«e-*ir«d wits c«acr»- 

atre*. X 6. 

They *re difficult to diatiaguiefe- 

rtrt Oft o/> 

Group 13-15 (3) 

Med lost- • ized ehrottOSOtsw* with tetasi- 

#4 *0 

Croup 16-18 (E } 

ftathor short cbxawoaoo** with aedian 

a*i (acrocescrie) crustro******- 13 
has prosaiaaot *4cellit« on tbs *hert 
ara, 14 has a *a*U satellite, sod 
15 has ac sate II it* - * 

or Subaedian ceacroewres. 


A 4 * 

Group It- 20 (D 

Short ehrow:<eos«*a wit* *a*di*o 21-22, T (G) 

cwatroocrea. Very abort Acrocentric cfcroe&toaea 

with 21 &**!&« * Mcellita on it* 

Fig. 5. Turner’s syndrome is associated with the XO 
karyotype seen here. The normal female has two 
X-chromosomes. 

ment of the cortex and cranial vault, the olfac- 
tory tracts, the eyes and the auditory apparatus, 
defects of heart, gastrointestinal tract, and geni- 
to-urinary system are common. Myoclonic seiz- 
ures and apneic episodes are often present 
also. 13 ’ 14 

Group E-Trisomy— Cases of trisomy of a chro- 
mosome in the 16, 17 and 18 group are associated 
with hypertonic musculature, VSD, horseshoe 
kidney, mental retardation and malformed ears. 
In addition, a peculiar clinching of the fingers 
with the first tending to overlie the third is 
often seen. Again the prognosis is poor. Seventy- 


one per cent of the affected children are females, 
suggesting that in utero selection against males 
may be present. In this syndrome as well as in 
the Group D-trisomy, buccal smears are nor- 
mal. 13, 14 

Summary 

Chromosome defects are much more frequent 
than previously supposed. Laboratory technics 
are outlined and the suggested etiologies and 
mechanisms are reviewed. Mongolism, Turner’s 
and Klinefelter’s syndromes, Triple-X, D-trisomy 
and E-trisomv are briefly described. Laboratory 
investigation of these and other defects is now 
possible and the results are often important in 
determining prognosis and treatment as well as 
in genetic counselling. 

Bibliography 

1. Barr, M. L., and Bertram, E. G. : A Morphologic Dis- 
tinction Between the Neurones of the Male and Female, and 
the Behavior of the Nucleolar Satellite During Accelerated 
Nucleoprotein Synthesis, Nature 163 :676, 1949. 

2. Tjio, J. H., and Levan, A. : The Chromosomes of Man, 
Hereditas 42 :1, 1956. 

3. Lejeune, J. M. ; Gautier, M.. and Turpin, M. R. : Genetique : 
Etudes des chromosome somatiques de Neuf enfants mongoliens. 
Comptes rendus des seances de l’Academie des Sciences 248 : 
1721-1722, 1959. 

4. Lyon, M. F. : Nature 190 :372, 1961. 

5. Russell, L. B. : Mammalian X-Chromosome Action, Science 
140 :976-978, 1963. 

6. Book, J. A., et al. : Proposed Standard System of Nomen- 
clature of Human Mitotic Chromosomes, Lancet 1:1063-1065, 
1960. 

7. Ohno, S. ; Trujillo, J. M. : Kaplan, W. D., and Kinosita, R. : 
Nucleolus-organizers in the Causation of Chromosomal Anom- 
alies in Man, Lancet 2 : 123-125, 1961. 

8. Eggen, R. R. : Cytogenetics, Am. J. Clin. Path. 39:3-37, 
1963. 

9. Jones, et al. : Pathology and Cytogenetics of Gonadal 

Agenesis, Am. J. Obst. & Gynec. 87 :578-600, 1963. 

10. Haddad, H. M., and Wilkin, L. : Congenital Anomalies 
Associated with Gonadal Aplasia. A Review of Fifty-five cases, 
Pediat. 23 :885-902, 1959. 

11. Tough, I. M. ; Court Brown, W. M. ; Baikie, A. G. ; Buck- 
ton, K. E. ; Jacobs, P. A.; King, M. J., and McBride, J. A.: 
Cytogenetic Studies in Chronic Myeloid Leukemia and Acute 
Leukemia Associated with Mongolism, Lancet 1 :411-417, 1961. 

12. Day, R. W. ; Larson, W., and Wright, S. W. : Clinical 
and Cytogenetic Studies on a Group of Females with XXX 
Sex Chromosome Complements. J. Pediat. 64 :23-33, 1964. 

13. Zellweger, H. ; Abbo, G. ; Beck, K. ; Neunzert, R., and 
Schnur, R. : Autosomal and Sex Chromosomal Aneuploidy. An 
Exhibit, J. Iowa M. S. pp. 735-752 (November) 1963. 

14. Smith, D. W. : The Number 18 Trisomy and Group 

D-Trisomy Syndromes, Pediat. Clin. N. Amer. 10:389-407, 1963. 


JOHN H. LANDOR, M.D., and 
W. KERMIT BAKER, M.D., Columbia 


Clinical Experience With Gastric 
Hypothermia in the Treatment of 
Upper Gastrointestinal Hemorrhage 


In 1958, Wangensteen and associates 1 demon- 
strated that lowering the temperature of the 
stomach resulted in a reduction in gastric se- 
cretion and a marked inhibition of peptic di- 
gestion. They suggested that local gastric cooling 
could be used therapeutically in the treatment 
of upper gastrointestinal bleeding, and reported 
on its use in five patients. More recently, blood 
flow measurements 2, 3 have shown that gastric 
hypothermia brings about striking reduction in 


Recent experience with localized gastric 
hypothermia in the treatment of 15 patients 
with upper gastrointestinal hemorrhage is 
reviewed. Control of bleeding was achieved 
in the majority of these patients soon after 
the initiation of gastric cooling, and emer- 
gency surgery was necessary in only a few 
cases. It is believed that this technic, when 
used with proper care and awareness of po- 
tential hazards, is deserving of further clin- 
ical trial. 

Dr. Landor is Associate Professor of Sur- 
gery and Dr. Baker is a Resident in Sur- 
gery at the University of Missouri School 
of Medicine. 


blood flow to the stomach and, in addition, a 
reduction in blood flow through the hepatic 
artery, superior mesenteric artery and portal 
vein. This effect on blood flow to the upper ab- 
dominal viscera is likely more important in 
achieving control of upper gastrointestinal tract 
hemorrhage than is the reduction in the secretion 
of acid and pepsin by the stomach. 

Numerous recent reports of experience with 
gastric hypothermia have appeared in the litera- 
ture, 4-11 and most authors are in agreement that 
the technic is useful in controlling hemorrhage 
in certain instances. Permanent control of bleed- 


ing has been achieved in the vast majority of 
patients with duodenal ulcer, but control has not 
been achieved so uniformly in patients with 
bleeding gastric ulcer. The success of gastric hy- 
pothermia in the treatment of bleeding from 
other conditions such as hemorrhagic gastritis, 
stress ulcer, blood dyscrasias, steroid ulcer, post- 
operative bleeding and neoplasm has been vari- 
able. Although localized cooling has controlled 
bleeding from esophageal varices in a high pro- 
portion of cases, there is still some question as 
to whether over-all mortality rates in this most 
grave condition have been lowered appreciably 
by its use. 

From September 1, 1962, to June 30, 1963, we 
have used gastric hypothermia in attempting to 
control upper gastrointestinal bleeding in 15 pa- 
tients, and it is our experience with these pa- 
tients which forms the basis for this report. A 
commercially available gastric hypothermia 
unit 0 which circulates a coolant solution was 
used, and the technic was essentially that de- 
scribed by Nicoloff, et al. 7 After passing a Levin 
tube and an Ewald tube into the stomach, cold 
saline was infused through the Levin tube, and 
the Ewald tube was aspirated until the return 
was clear. The vomiting which often accom- 
panied passage of the Ewald tube sometimes 
proved more efficacious in emptying the stomach 
of large clots than did the irrigation. The Ewald 
tube was removed and the Levin tube allowed 
to remain in place for aspiration during gastric 
cooling. After the pharynx was sprayed with a 
topical anesthetic agent, the lubricated gastric 
balloon attached to the double lumen plastic 
tubing was passed into the stomach. The balloon 
was slowly inflated with from 200 to 250 cc. of 
fluid and, with gentle traction on the tubing, the 
upper end of the balloon was seated in the 
cardia. The balloon was then further inflated 
until the patient noted a feeling of fullness ( from 

* Swenko Gastric Hypothermia Machine. 


292 


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293 


600 to 1100 cc.), at which point circulation of 
the coolant solution was begun and the volume 
within the balloon was maintained at a constant 
level. Inflow temperatures of 5 to 10 C. were 
utilized and cooling was continued for at least 
18 hours after cessation of hemorrhage. A warm- 
ing blanket was used to avoid marked lowering 
of body temperature and a thermistor probe was 
placed in the rectum in order to monitor body 
temperature. Since gastric secretion rapidly re- 
turns to normal or above normal levels after 
cessation of cooling, 2 a continuous drip of skim 
milk was instituted via the Levin tube as soon 
as the gastric balloon had been removed. If tube 
feeding was deemed potentially hazardous be- 
cause of paralytic ileus or extreme debility of 
the patient, nasogastric suction was instituted 
and continued until a milk drip could be tol- 
erated. 

Although some of the patients in our series 
had persistent bleeding despite attempts at medi- 
cal management and were not good candidates 
for surgery, others were subjected to gastric hy- 
pothermia without a trial on conventional man- 
agement. This was particularly true as we gained 
more experience with the technic. A high degree 
of success in treating the first few patients led 
us to the conclusion that gastric hypothermia 
was more likely to result in prompt slowing or 
cessation of hemorrhage than was any other non- 
operative approach and, consequently, many pa- 
tients were treated by this technic without wait- 
ing for a trial on other medical management. 
We feel strongly that those patients who ulti- 
mately require surgery for definitive manage- 
ment of the lesion responsible for hemorrhage 
will have a lower morbidity and mortality if 
bleeding can be controlled by nonoperative 
means, allowing time for proper evaluation and 
preparation of the patient for elective surgery. In 
those patients who are bleeding as the result of 
disease processes which are completely reversi- 
ble by time and medical therapy, operation can 
be avoided completely if the hemorrhage can 
be stemmed. 

Clinical Experience 

Duodenal Ulcer 

J. F. was a 65 year old white male with a history 
of hematemesis and melena of several hours dura- 
tion. Hematocrit on admission was 28 per cent. After 
typing and cross-matching, transfusions were started 
and gastric hypothermia was instituted. During the 
next 18 hours, the patient required 12 units of blood 
to maintain the hematocrit at from 30 to 32 per cent. 
In the face of continued bleeding, he was taken to 


the operating room where exploration revealed a 
prepyloric ulcer, an ulcer in the duodenal bulb and 
a third ulcer in the second portion of the duodenum. 
Suture ligature of the ulcers and vagotomy-pyloro- 
plasty were carried out. Recovery was uneventful. 

K. M. was a 72 year old white male with a history 
of previously demonstrated duodenal ulcer who had 
been having tarry stools for two weeks. Shortly after 
admission, he had massive hematemesis, became 
hypotensive and suffered a cerebrovascular accident 
which left him comatose and hemiplegic. Bleeding 
continued and gastric cooling was begun with 
prompt control of hemorrhage and stabilization of 
vital signs. Hypothermia was discontinued after 36 
hours and there was no further bleeding. The pa- 
tient never regained consciousness, however, and 
developed bilateral pneumonia. He went progres- 
sively downhill and died six days after admission. 
Autopsy was not obtained. 

Comment: Failure to control the first patient 
may have been due to the fact that one of the 
ulcers was more distal in the duodenum than 
usual and blood flow to this area is probably not 
reduced appreciably by gastric cooling. Peter, 
et al. 3 have shown a reduction of 58 per cent in 
blood flow to the stomach and 51.6 per cent in 
blood flow through the hepatic artery, but only 
a 23 per cent reduction in blood flow through the 
superior mesenteric artery. Although the ulti- 
mate fatal outcome in the second patient vitiates 
the success of the treatment for bleeding, prompt 
control of hemorrhage by means of gastric hypo- 
thermia was striking. 

Gastric Ulcer 

F. H. was a 41 year old white female who had had 
hematemesis and melena during the previous two 
days and had received four blood transfusions. On 
admission to the University of Missouri Medical 
Center, the hematocrit was 15 per cent. A continu- 
ous drip of skim milk was started and she was given 
six more units of blood during the next 24 hours. 
She then developed massive hematemesis and gastric 
hypothermia was begun. Eighteen units of blood 
were given during the next eight hours and the 
hemorrhage finally ceased. Several days later an 
upper gastrointestinal series was nondiagnostic. On 
the eighth hospital day, she had another massive 
hemorrhage and was taken to the operating room. 
Exploratory laparotomy revealed a bleeding gastric 
ulcer and a subtotal gastrectomy was carried out. 
The postoperative course was complicated by pul- 
monary embolus, but the patient had no further 
difficulty after this episode and was discharged on 
the twelfth postoperative day. 

E. A. J. was a 60 year old white male who was 
transferred to the University of Missouri Medical 
Center with a three day history of upper gastroin- 
testinal bleeding manifested by hematemesis and 
melena. Blood loss had continued after administra- 


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Missouri Medicine 
April, 1964 


tion of six pints of blood. On admission to the Uni- 
versity of Missouri Medical Center, the patient was 
in shock with a pulse of 130 and blood pressure of 
80/50. Approximately 1,500 cc. of bright red blood 
and clots were aspirated from the stomach with an 
Ewald tube. Following the rapid administration of 
1,500 cc. of blood, the blood pressure was 120/70, 
but there was a continuous flow of bright red blood 
from the Levin tube. Accordingly, gastric hypother- 
mia was started approximately one and one half 
hours after admission. The passage of the tube and 
balloon was accompanied by a sudden worsening 
of the patient’s general condition. There was a rapid 
development of cyanosis accompanied by the pro- 
duction of frothy, bloody sputum, and aspiration of 
blood into the air passages was believed to have oc- 
curred. Despite resuscitative efforts in the form of 
whole blood, endotracheal intubation and, finally, 
closed chest cardiac massage, the patient deterior- 
ated rapidly and died three hours after admission. 
Autopsy revealed a 4 cm. greater curvature gastric- 
ulcer (benign). The heart, lungs and upper air 
passages were, essentially, within normal limits. The 
patient did not appear to have expired from tracheo- 
bronchial aspiration and obstruction. 

Comment: Gastric cooling accomplished little 
in these two patients with bleeding gastric ulcers 
and it is possible that it may have contributed to 
the death of the second patient. F. H. was the 
first patient on whom we used the gastric hypo- 
thermia machine and, because of our inexperi- 
ence, we persisted in the use of gastric cooling 
for what we now consider to be an inordinate 
period of time in the face of continued heavy 
bleeding. We were fortunate in not encountering 
serious difficulty from the administration of large 
quantities of blood during such a short period of 
time. Although temporary control of bleeding 
was ultimately achieved by gastric cooling, the 
patient bled a second time and underwent emer- 
gency gastrectomy. 

The sudden worsening of the second patient’s 
condition coincident with the passage of the 
tube and balloon was initially believed to be 
the result of injury from passage of the tube. 
Autopsy failed to bear this out and it was con- 
cluded that the patient died of the effects of 
continued blood loss and shock. It is possible 
that the stomach was not completely emptied of 
blood and clots before institution of gastric hypo- 
thermia. 

Postoperative Hemorrhage 

S. C. was a 67 year old white female who under- 
went a cholecystectomy and choledochostomy with 
removal of common duct stones. She had a pulmo- 
nary embolus on the fourth postoperative day and 
again on the sixth postoperative day. Transient im- 
provement followed vena cava ligation, but on the 


10th postoperative day she vomited coffee ground 
material and the hematocrit began to decline. She 
continued to have occasional coffee ground emesis 
during the next few days and then began vomiting 
bright red blood. Gastric hypothermia was instituted 
with prompt control of bleeding and there were no 
further episodes of hemorrhage. However, she went 
on to develop acute pancreatitis, wound dehiscence, 
pneumonitis and staphylococcal enteritis and ex- 
pired. 

E. M. was an 82 year old white female who un- 
derwent operative closure of a perforated duodenal 
ulcer. Her postoperative course was complicated by 
gastric retention, and, on the seventh postoperative 
day, she developed massive hematemesis and went 
into shock. Blood transfusions were started and gas- 
tric hypothermia was begun with rapid improvement 
in vital signs and cessation of hemorrhage. She had 
no further episodes of bleeding. A temporary feeding 
jejunostomy was performed because of persistent 
pyloric obstruction, and, after a few days on tube 
feedings gastric emptying returned to normal. She 
was then placed on oral feedings and the remainder 
of her course was uneventful. 

W. G. was a 59 year old Negro male who was 
admitted in shock with an acute abdomen. The 
blood pressure stabilized at normal levels after 
treatment with blood, plasma and intravenous fluids. 
After exploratory laparotomy revealed a perforated 
duodenal ulcer with severe purulent peritonitis, sim- 
ple closure of the perforation was carried out. He 
had a stormy postoperative course with high spiking 
fever and prolonged paralytic ileus. Several bouts 
of moderate hematemesis seemed to respond to con- 
servative measures, but, on the 13th postoperative 
day, he developed massive hematemesis requiring 
four units of blood during a six hour period. Gastric- 
hypothermia was begun and there was no further 
evidence of fresh bleeding. He continued to have a 
stormy course during the next week, but had no 
further gastrointestinal bleeding. He gradually im- 
proved and was discharged on the 52nd postoper- 
ative day. 

Comment: All three of these patients were 
critically ill when bleeding was first noted. It 
was our feeling that operative intervention to 
control hemorrhage, had it been necessary, 
would almost certainly have been fatal in each 
instance. Gastric hypothermia controlled the 
bleeding in each patient and we believe that it 
was life-saving in the two patients who survived. 

Stress Ulcers 

C. R. was an 82 year old white female who sus- 
tained a 20 per cent body burn and was admitted 
two weeks post-bum for debridement and skin graft- 
ing. On the 35th post-bum day she developed 
melena and a decline in the hematocrit. After a 
brief unsuccessful trial on a medical regimen, gastric 
cooling was started with prompt stabilization of the 


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295 


hematocrit. Although there was no further evidence 
of bleeding, the patient developed pneumonitis and 
signs of generalized sepsis and expired on the 46th 
post-bum day. Autopsy revealed a healing acute 
ulcer in the second portion of the duodenum. 

C. D. was a 29 year old white male who was 
found unconscious along a highway. Evaluation 
revealed a quadriplegia resulting from fracture of 
the spine at the c-6 level as well as a head injury. 
During the next few days the sensorium began to 
clear and the patient was begun on oral intake. On 
the seventh hospital day the hematocrit was noted 
to be 19 per cent and he developed gross melena. 
During the next 48 hours he required 14 units of 
blood and continued to pass tarry stools. Gastric 
hypothermia was instituted with prompt slowing and 
eventual cessation of bleeding. He underwent cer- 
vical spinal fusion on the 20th hospital day and the 
remainder of his course was uncomplicated. 

Comment: Although stress ulcer was not prov- 
en in the second patient, it would seem to be 
the most likely cause of hemorrhage in such a 
person with marked trauma to the central ner- 
vous system. The permanent control of bleeding 
by gastric cooling in both of these patients was 
extremely gratifying because of the expected 
high mortality from this complication in the se- 
verely injured patient. Unfortunately, the burn 
patient lived only 11 days after the bleeding 
episode and it can not be said with certainty 
that further episodes of bleeding from the “Curl- 
ings” ulcer would not have occurred had she 
lived longer. However, on the basis of this ex- 
perience, we feel that gastric hypothermia cer- 
tainly merits a thorough trial when this almost 
uniformly fatal complication appears in a se- 
verely burned patient. 

Unknown Source of Bleeding 

M. M. was a 43 year old white female who had 
an episode of vomiting followed shortly afterward 
by hematemesis and melena. She received eight 
units of blood at another hospital during a 12 hour 
period and continued to bleed massively. On admis- 
sion to the University of Missouri Medical Center, 
gastric hypothermia was begun and there seemed 
to be prompt slowing of the hemorrhage. However, 
at the end of six hours a rise in the pulse rate and 
decline in the blood pressure were noted along with 
evidence of fresh bleeding. The patient was taken 
to the operating room where careful exploration of 
the stomach and the first portion of the duodenum 
revealed no active bleeding. There were a few super- 
ficial erosions in the distal stomach and a linear fur- 
row covered with exudate in the mucosa of the car- 
dia. Because of uncertainty as to the site of bleed- 
ing, the furrow in the cardia was oversewn and a 
subtotal gastrectomy was carried out. Recovery was 
rapid and uneventful. 


F. T. was a 62 year old white male who had been 
hospitalized elsewhere for pneumonia and devel- 
oped melena in the hospital. Eleven units of blood 
were given over a nine day period and he then de- 
veloped massive hematemesis requiring 15 units of 
blood in approximately 18 hours. On admission to 
the University of Missouri Medical Center, gastric 
cooling was instituted and, during the next 28 hours, 
four units of blood brought the hematocrit from 23 
per cent to 36 per cent. Marked hemorrhage then 
recurred and laparotomy was carried out. No active 
bleeding was seen in the stomach or duodenum but 
several superficial ulcerations were visible in the 
cardiac portion of the stomach. These were over- 
sewn and vagotomy-pyloroplasty was done. After 
a difficult postoperative course complicated by con- 
tinued pneumonitis and wound dehiscence, the pa- 
tient recovered and was discharged. 

Comment: Although gastric cooling did not 
result in permanent control of hemorrhage in 
either of these two patients, it did bring about 
a marked decrease in the rate of bleeding or tem- 
porary cessation of bleeding. Both patients rep- 
resented difficult problems in surgical judgement 
since the source of bleeding could not be identi- 
fied with certainty. The first patient could well 
have represented the “Mallory-Weiss” syndrome, 
but the presence of erosions in the distal stomach 
led us to carry out gastric resection. Vagotomy 
was done in the second patient because the ero- 
sions were high in the stomach and because we 
wished to do a procedure less formidable than 
gastrectomy in this seriously ill patient. The 
presence of superficial erosions in both patients 
raised the question of whether or not these 
lesions may have resulted from trauma from the 
gastric balloon or mucosal damage from the 
gastric cooling. We have noted no similar lesions 
in our other two patients who underwent sur- 
gery following gastric hypothermia, nor have 
such lesions been reported by others. 

Miscellaneous 

J. U. was a 51 year old white male with steator- 
rhea thought to be secondary to post-gastrectomy 
“blind loop syndrome.” He experienced massive up- 
per gastrointestinal bleeding which was promptly 
controlled by gastric hypothermia. The prothrombin 
time was found to be markedly prolonged and, after 
Vitamin K therapy had brought the prothrombin 
time to normal, gastric cooling was discontinued 
with no further evidence of bleeding. 

C. W. was a 53 year old white male who had a 
massive upper gastrointestinal hemorrhage three 
months after a Billroth I gastrectomy for bleeding 
gastric ulcer. Bleeding ceased rapidly after gastric 
cooling was begun and there was no further hem- 
orrhage. Upper gastrointestinal x-ray revealed a 


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Missouri Medicine 
April, 1&64 


marginal ulcer in the duodenum, and, after an un- 
successful trial on medical management for two 
months, he underwent bilateral vagotomy. 

W. T. was a 74 year old white male who had ab- 
dominal exploration for what proved to be a non- 
resectable abdominal aortic aneurysm. His post- 
operative course was complicated by staphylococcal 
pneumonia and, on the 17th postoperative day, he 
developed massive upper gastrointestinal hemor- 
rhage. This was promptly controlled by gastric hypo- 
thermia, but attempts at discontinuation of gastric 
cooling led to further bleeding. His course was pro- 
gressively downhill and autopsy revealed multiple 
erosions of esophagus, stomach and duodenum. 
Monilia was cultured from this area. 

T. H. was a 71 year old white male who had had 
melena for two weeks. Evaluation revealed conges- 
tive heart failure, pneumonitis and blood in the 
stomach aspirate. Upper gastrointestinal x-rays were 
not diagnostic. Medical management failed to con- 
trol the hemorrhage but it was controlled success- 
fully by gastric hypothermia on two separate occa- 
sions. However, his congestive failure proved to be 
intractable and he expired as a result of pneumonitis 
and pulmonary edema. Autopsy revealed an ulcer- 
ated carcinoma of the stomach. 

Comment: Although the control of bleeding 
due to a defect in the clotting mechanism has 
not been uniformly successful in the hands of 
others, it proved helpful to us in the case of 
bleeding due to prothrombin deficiency and 
would seem deserving of further trial as a tem- 
porary measure in the patient with a correctable 
clotting defect. The prompt cessation of hemor- 
rhage in the patient with stomal ulcer was grati- 
fying, and, although he ultimately required sur- 


gery for control of the peptic ulcer diathesis, an 
emergency procedure in a massively bleeding in- 
dividual was avoided. The remaining two pa- 
tients provide examples of the efficacy of gastric 
hypothermia, but the etiology of the bleeding 
was such that permanent control could not be 
expected. We would not advocate the use of 
gastric hypothermia in the patient who is bleed- 
ing from a known gastric neoplasm except per- 
haps for temporary control of bleeding until 
definitive resection could be carried out. 

Discussion 

Table 1 summarizes the results in these 15 
patients. It can be seen that control of hemor- 
rhage was achieved by gastric hypothermia in 
nine patients and bleeding was temporarily con- 
trolled in an additional two patients. Although 
generalization is not possible on the basis of 
experience with such a small group of patients, 
we feel that this technic was particularly useful, 
and in some cases life-saving, in the patients with 
postoperative hemorrhage and those with stress 
ulceration. 

The question of selection of patients for gas- 
tric hypothermia is one that can only be an- 
swered after much more extensive use of this 
technic in large numbers of patients. Our results 
have been sufficiently encouraging so that we 
feel that gastric hypothermia deserves further 
trial in all patients who are bleeding massively 
from the upper gastrointestinal tract and should 
be used without prior attempts at conventional 
medical management in this type of patient. We 


TABLE 1 

SUMMARY OF PATIENTS TREATED BY MEANS OF GASTRIC HYPOTHERMIA 


Patient 

Cause of Bleeding 

Bleeding Controlled 
by Hypothermia 

Operation for Control 
of Hemorrhage 

Death 

JF. 

Duodenal ulcer 

No 

Yes 


K.M. 

Duodenal ulcer 

Yes 

No 

Yes ( other causes ) 

F.H. 

Gastric ulcer 

Temporarily 

Yes 


E.J. 

Gastric ulcer 

No 

No 

Yes 

S.C. 

Postoperative hemorrhage 

Yes 

No 

Yes ( other causes ) 

E.M. 

Postoperative hemorrhage 

Yes 

No 


W.G. 

Postoperative hemorrhage 

Yes 

No 


C.R. 

Stress ulcer 

Yes 

No 

Yes ( other causes ) 

C.B. 

Stress ulcer 

Yes 

No 


M.M. 

Unknown 

No 

Yes 


F.T. 

Unknown 

No 

Yes 


J.U. 

Prolonged prothrombin time 

Yes 

No 


C.W. 

Stomal ulcer ( duodenal ) 

Yes 

No 


W.T. 

Moniliasis 

Temporarily 

No 

Yes 

C.H. 

Gastric carcinoma 

Yes 

No 

Yes ( other causes ) 


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297 


also feel that gastric cooling is indicated in the 
patient who is bleeding at a slower rate but who 
fails to respond to medical management. In the 
patient who continues to require large volumes 
of blood for replacement after two to three hours 
of gastric cooling, prompt surgical intervention 
would seem indicated, for the hazards of con- 
tinued massive transfusion with banked blood 
begin to outweigh the risk of surgery. 

We have had no serious complications directly 
attributable to gastric hypothermia except that 
one patient (E. J. ) died early in the course of 
gastric cooling and it cannot be ascertained with 
certainty that the institution of gastric cooling 
was not related to this sudden death. It is pos- 
sible that gastric hypothermia may have con- 
tributed to the development of pneumonia in 
several of our patients, but these were patients 
who were seriously ill with debilitating disease 
and who might be expected to develop pulmo- 
nary complication because of the nature of their 
disease. At any rate, meticulous care of tracheo- 
bronchial secretions is important in any patient 
with an indwelling gastric tube, particularly a 
tube of large caliber such as that used with the 
gastric hypothermia machine. We now feel that 
any patient who manifests difficulty in handling 
secretions while undergoing gastric cooling 
should have a prophylactic tracheostomy per- 
formed so that frequent suctioning of the trachea 
and bronchi can be carried out with ease and 
efficiency. 

Careful attention to detail is necessary if 
hazards are to be avoided and success achieved. 
Gastric rupture has been reported by others, 
6, 7, 8, n an q ma y resu |t; from inflating the bal- 
loon in a stomach not properly emptied of blood 
clots or from the accumulation of air in the ma- 


chine displacing more and more fluid into the 
balloon. The latter mechanism has been obviated 
by a safety device incorporated in the machine 
which warns of the presence of air. It is essential 
that trained personnel be with the patient con- 
stantly to monitor factors such as volume of fluid 
in the balloon, temperature of the coolant solu- 
tion and body temperature of the patient, and 
a physician familiar with the patient and with 
the technic of gastric hypothermia must be readi- 
ly available. Catastrophe was narrowly averted 
in one of our patients when it was discovered 
that the inflow temperature of the circulating 
alcohol had drifted down to -20 C. Apparently 
this temperature had not been maintained for a 
long enough time to produce necrosis of the 
stomach wall. 


Bibliography 

1. Wangensteen, O. H. ; Root, H. D. ; Jenson, C. B. ; Imamoglu, 
K., and Salmon, P. A. : Depression of Gastric Secretion and 
Digestion by Gastric Hypothermia: Its Clinical Use in Massive 
Hematemesis, Surg. 44 :265, 1958. 

2. Wangensteen, O. H. ; Salmon, P. A.; Griffin, W. O. Jr.; 
Paterson, J. R. S., and Fattah, F. : Studies of Local Gastric 
Cooling as Related to Peptic Ulcer, Ann. Surg. 150:346, 1959. 

3. Peter, E. T. ; Nicoloff, D. N. ; Bernstein, E. F. ; Walter, 
A. I., and Wangensteen, O. H. : The Effect of Gastric Hypo- 
thermia on Splanchnic Hemodynamics in the Dog, J. Surg. 
Research 3 :32, 1963. 

4. Holt, M. H. : Gastric Cooling for Upper GI Bleeding: A 
Simplified Technique and Its Clinical Trial, W. Va. Med. J. 
58:338, 1962. 

5. Kelley, H. G. ; Grant, G. N., and Elliott, D. W. : Massive 
Gastroduodenal Hemorrhage, Arch. Surg. 87 :6, 1963. 

6. Miller, R. E. ; Moscarella, A. A., and Fitzpatrick, H. F. : 
Local Gastric Hypothermia, Arch. Surg. 86 :272, 1963. 

7. Nicoloff, D. M. ; Griffin, W. O. Jr. ; Salmon, P. A. ; Peter, 
E. T., and Wangensteen, O. H. : Local Gastric Hypothermia in 
the Management of Massive Gastrointestinal Hemorrhage, Surg. 
Gynec. & Obst. 114:495, 1962. 

8. Richman, A., and Anthony, D. : Experiences With Localized 
Gastric Hypothermia in Massive Upper Gastrointestinal Bleed- 
ing, Am. J. Dig. Dis. 8:113, 1963. 

9. Turner, G. R. ; Hinshaw, D. B. ; Carter, R., and Vannix, 
R. S. : Local Gastric Hypothermia in Management of Massive 
Upper Gastrointestinal Hemorrhage, Surg. 53 :609, 1963. 

10. Wangensteen, S. L. : Intragastric Cooling for Upper Gas- 
trointestinal Hemorrhage, Surg. Clin. N. Amer. 42 :1171, 1962. 

11. Wangensteen, S. L. ; Orahood, R. C. ; Voorhees, A. B. ; 
Smith, R. B. Ill, and Healey, W. V. : Intragastric Cooling in the 
Management of Hemorrhage From the Upper Gastrointestinal 
Tract, Am. J. Surg. 105 :401, 1963. 


ROBERT Q. MARSTON, M.D., Jackson , Miss. 


A Proper Reference 

Special Article 


First, let me congratulate all who have made 
it possible for this precommencement ceremony 
to occur, those who have contributed to the 
founding of this impressive medical center, those 
who are responsible for its day-by-day function, 
those who have made it possible for these seniors 
to graduate today. Seniors, let me congratulate 
you on your presence here. This, in itself, is rec- 
ognition of accomplishments of great signifi- 
cance. 

A little more than ten years ago, I stood on 
Frenchman Flats about 70 miles from Las Vegas 
with other members of the Armed Forces Special 
Weapons Project watching the detonation of a 
conventional atomic bomb. We were 10 miles 
from the bomb on a hill, and the day before I 
had been allowed to go to the top of the tower, 
300 feet high, which held the bomb. This dis- 
tance was chosen because the periphery of the 
fireball itself would just touch the ground after 
explosion of a 30-plus kiloton atomic bomb. In 
the cold early dawn the fireball was followed 
rapidly by the mushroom cloud and I was aware 
that my whole visual field seemed to be filled 
by the explosion 10 miles away. A few years 
later when the first megaton hydrogen bomb 
was exploded in the Pacific, one of my friends 
explained its magnitude to me by saying that 
from a 100 mile distance, it was like looking at 
a 30 kiloton explosion from 10 miles away. He 
was able to use a reference which had a meaning 
to me. 

All commencement speakers would like to say 
things that are meaningful to graduating seniors; 
yet all know the high probability that the really 
important things have already been said many 
times before— such things as those having to do 
with truth, the nature of man, with the goals of 
education, the goals of medicine and with other 
eternals. The best that can be done is to try to 
pick a reference that has a significance, an im- 
port, for the listeners. As an aside, one might re- 
member that the best-selling book, or the books 
that become classics, do so because the reader 
finds special meaning in terms of his own experi- 
ences in what the author has written. The proper 
reference that I have chosen to emphasize today 
is the reference that you should have to yourself, 
to your profession, and to your society; and 


This was presented as a Precommence- 
ment Address at the University of Missouri 
Medical Center, Columbia, on June 4, 1963. 

Dr. Marston is Director and Dean of the 
University of Mississippi Medical Center, 
Jackson, Miss. 


though I shall use many words, all that I shall 
say could be summarized in the phrase, “Know 
thyself.” 

In choosing the profession of medicine, you 
are inevitably seeking goals which must be high- 
er than the satisfaction of personal ambition. In 
medicine you will find many rewards, but I 
believe that those of you who remain sensitive 
and clear in your goals will know what William 
Faulkner meant in the first paragraph of his 
Nobel Prize acceptance speech, and I quote: 

“I feel that this award was not made to me as 
a man, but to my work— a lifework in the agony 
and sweat of the human spirit, not for glory and 
least of all for profit, but to create out of the 
materials of the human spirit something which 
did not exist before; so this award is only mine 
in trust. It will not be difficult to find a dedica- 
tion for the money part of it commensurate with 
the purpose and significance of its origin. But I 
would like to do the same with the acclaim too, 
by using this moment as a pinnacle from which 
I might be listened to by the young men and 
women already dedicated to the same anguish 
and travail, among whom is already that one 
who will someday stand here where I am stand- 
ing.” 

Faulkner’s subjects were the deepest known 
to man— hate, lust, despair, injustice, love and 
friendship. The very nature of medicine means 
that you will contact every deep and meaningful 
experience that mankind knows, and your liveli- 
hood, in a sense, will come from the pain and 
suffering of your fellow man. If from this cir- 
cumstance you seek fame, fortune and esteem 
alone, then you will become the most pitiable of 
men, in truth, parasites on society. Your re- 
sponsibilities go beyond the saving of lives, the 
prolongation of life, the alleviation of suffering. 


Volume 61 
Number 4 


A PROPER REFERENCE— MARST ON 


299 


and include attempts to increase the meaningful- 
ness, the effectiveness and the enjoyment of the 
lives of your fellow man. 

In psychiatry, you have been taught that you 
must substitute your own reactions for the ruler, 
the balance, the radio-isotope counter and other 
objective measuring devices, as a standard 
against which you measure your patient’s health. 
An inaccurate ruler can only result in an inac- 
curate measurement, and thus an inaccurate con- 
clusion. You know, too, by this time that this ex- 
ample is not limited to psychiatry. Through the 
years, you have been advised to treat your pa- 
tients as if they were members of your own fam- 
ilies. In a sense, this is medicine’s own interpreta- 
tion of the golden rule. 

Those in medicine must keep their eyes rela- 
tively free of motes, not only to protect indi- 
vidual patients but for the welfare of the pro- 
fession and of society. 

So, let us leave the individual for a moment 
and consider Max Lerner’s concept of why 
civilizations fail. In a December 1962 article in 
the Saturday Review , he sets forth the thesis 
that civilizations fail because of rigidity and 
various other factors, but most of all because 
they cease to know themselves and live with a 
distorted image of their world and of them- 
selves. Individuals who truly lose contact with 
reality lose their effectiveness, lose their ability 
to enjoy life and are considered sick. Medicine 
must keep its goals clear and be sure they are 
properly related to the broader goals of society. 

Few professions require that the individual 
have as clear and honest a concept of himself 
as does medicine. To realize this objectivity, you 
have been in a position to study the depths of 
the human soul as can no other, not casually or 
curiously, but within the framework of the most 
highly developed system of science that the 
world has ever known. 

I am interested in viruses. The developments 
in this field in the last fifteen years remind one 
dramatically that the useful life of technical in- 
formation has become much shorter than the 
professional life of the individual. Most of what 
you learn and use in your lifetime will be learned 
after you leave medical school. How many of 
you, for instance, are prepared for the changes 
which discoveries in virology will have on the 
practice of medicine, or for the stimulus that 
these discoveries have had on related fields, 
such as genetics? Consider these examples of 
what has occurred during your brief scientific 
career: the extraction of the nucleic acid of puri- 
fied viruses and the use of this chemical to infect 
cells; the discovery of the process whereby ribo- 


nucleic acid acts as a messenger for the activa- 
tion of chemical reactions; the demonstration of 
synthesis not only of proteins but of artificial 
proteins from artificial ribonucleic acids; the 
demonstration of abnormalities in human chro- 
mosomes which correlate well not only with 
specific human disease but with specific bio- 
chemical impairments actually causing the dis- 
ease, and in some instances the application of 
knowledge gained from such discoveries to the 
prevention of the ill effects of the disease if not 
of the disease itself. Each of you could choose 
other examples, such as the recent synthesis of 
biologically active desoxyribonucleic acids. 

To maintain a proper reference, a proper 
understanding of ourselves and of our field, we 
will need some mechanism to keep informed of 
and to participate in the scientific advances in 
the field of biology, occurring at such a rate that 
it has been suggested we are in the midst of an 
explosion or revolution not unlike that which 
physics has recently experienced. 

To attain a proper perspective towards one’s 
own field, one will have to look outside from 
time to time. For instance, a new book entitled 
‘“Animal Species and Evolution” 1 by Ernst Mayr 
is, according to Sir Julian Huxley, indispensable 
for everyone interested in evolutionary biology. 
Some of Mayr’s comments are particularly per- 
tinent to us. He says: “The theory of evolution is 
quite rightly called the greatest unifying theory 
in biology. The diversity of organisms, similari- 
ties and differences between kinds of organisms, 
patterns of distribution and behavior, adaptation 
and interaction, all this was merely a bewilder- 
ing chaos of facts until given meaning by the 
evolutionary theory. There is no area in biology 
in which that theory has not served as an order- 
ing principle.” 2 And he adds: 

“But much as we know about the ‘how of 
human evolution, the ‘why’ is still a great puzzle. 
High intelligence and harmonious social integra- 
tion are undoubtedly attributes of high selective 
value, so much so, indeed that we may ask with 
Etkin (1954) ‘why all animals are not as intelli- 
gent as Einstein and as moral as Albert Schweit- 
zer?’ 3 4 . . . ‘Ethical’ qualities, in a social organism, 
are apt to be important components of fitness. 

”4 

Mayr makes the interesting observation that 
there has been no increase in brain size since 
the time of the Neanderthal man nearly a hun- 
dred thousand years ago, and no real evidence of 
improvement of the brain without an enlarge- 

1. Mayr, Ernst, Animal Species and Evolution, Belknap Press 
of Harvard University Press, Cambridge, Mass., 1963. 

2. Ibid., p. 1. 

3. Ibid., p. 650. 

4. Ibid., p. 651. 


300 


A PROPER REFERENCE— MARSTON 


Missouri Muhcine 
April, 1964 


ment of the cranial cavity, although this is, of 
course, always possible. 

And finally, in commenting on the threat to 
man’s highest attributes posed by the problem 
of overpopulation, Mayr concludes by saying: 
“Let us hope that the biological aspects of man’s 
evolution are duly taken into consideration by 
those entrusted with the task of planning for the 
future of mankind.” 5 

You as physicians will be involved in this 
planning and in so doing you will need to ap- 
preciate and work with evolutionary biologists 
and representatives from many other disciplines. 
Unfortunately it appears at times that we have 
enough difficulty just working with ourselves. 
There is concern that various schisms within 
medicine are reducing our effectiveness. Your 
Dean, with others, gave excellent leadership to 
an Association of American Medical Colleges 
Institute held last fall to develop constructive 
efforts to resolve some of the town-gown prob- 
lems. Our goal is not to avoid controversy or 
differences of opinion but to approach these di- 
visive problems neither selfishly nor defensively 
but from the common goal of seeking the de- 
livery of better health services. 

I trust that no one in this audience will fail 
in the early years of this Medical Center to ap- 

5. Ibid., p. 662. 


IRRADIATION 

(Continued from page 287) 

in some cases; in other cases it may tip the 
balance toward healing so that medical manage- 
ment can succeed; in some cases, the patient’s 
condition may improve so that he is a better 
candidate for surgery. 

Summary 

1. Irradiation c^n benefit many patients with 
peptic disease who have failed to be controlled 
by other forms of treatment. 

2. This type of irradiation (especially with 
supervoltage ) is conservative treatment. 

3. There is evidence to suggest that use of 
irradiation might save a considerable proportion 
of these patients ( whose disease is not controlled 
by a medical regimen) the necessity of being 
subjected to surgery. 

Bibliography 

1. Wilms : Roentgenbestrahlung bei pyeorospasmus, Munchen. 
med. Wchnschr. 63:1073-1074, 1916. 

2. Brugel, C. : Die Beeinflussung des Magenchemismus durch 
Roentgenstrahlen, Munchen. med. Wchnschr. 64 :379-380, 1917. 

3. Bryan, L., and Doronody, H. : Preliminary Report on the 
Effects of Roentgen Rays on Gastric Hyperacidity, Am. J. 
Roentgenol. 8 :623-628, 1921. 

4. Case, J. T., and Boldyreff, W. N. : Influence of Roentgen 
Rays Upon Gastric Secretion, Am. J. Roentgenol. 19 :61-70, 
1928. 


preciate the tremendous importance of such cen- 
ters to future life in this state and nation. Two 
years ago, I went as Dean to a center established 
about the same time. All of my previous experi- 
ence had been in educational institutions estab- 
lished a minimum of 100 or so years ago and, 
indeed, with one established in 1237. During the 
last two years, I have developed a tremendous 
respect and admiration for those in Mississippi 
and Missouri, in Kentucky, in West Virginia, in 
Washington state and elsewhere in this nation, 
who struck out to develop educational insti- 
tions which are the most expensive, the most 
complicated, the most highly competitive in 
terms of talent. From the moment some eight 
years ago that you became a four-year medical 
school and developed the Medical Center, the 
only acceptable reference for comparison has 
been the best in medical education in the coun- 
try. You who are graduating do so with the 
recognition that you leave this center with no 
limitations whatsoever so far as your education 
in the health fields is concerned. 

When one graduates for the second or third 
time, some degree of nonchalance might be ex- 
pected. Yet such is the nature of the M.D. de- 
gree that there is no possibility your achieve- 
ments will pass without appropriate serious no- 
tice. I salute each of you and wish you each 
Godspeed. 


6. Mcllrath, D. C. ; Hallenbeck, G. A. ; Allen, H. A. ; Mann, 
C. V. ; Baldes, E. J. ; Brown, A. L., and Rovelstad, R. A. : 
Hazards of Gastric Freezing, Gastroenterol. 45 :374-383. 

6. Delbet, P. ; Herrenschmidt, A., and Mocquot, P. : Action 
du radium sur l’estomac. Bull. Ass. franc, etude cancer. 2:103- 
119, 1909. 

7. Martin, C. L., and Rogers, F. T. : Intestinal Reaction to 
Erythema Dose, Am. J. Roentgenol. 10:11-19, 1923. 

8. Ivy, A. C. : Orndoff, B. H. ; Jacoby, A., and Whitlow, J. E. : 
Studies of the Effect of X-Rays on Glandular Activity. III. The 
Effect of X-Rays on Gastric Secretion, Radiol. 1 :39-44, 1923. 

9. Dawson, A. B. : Histologic Changes in the Gastric Mucosa 
of the Dog Following Irradiation, Am. J. Roentgenol. 13 :320- 
326, 1925. 

10. Lacassagne, A., and Gricouroff, G. : Action of Radiation 
on Tissues ; Grune and Stratton, Inc. ; New York ; 1958. 

11. Goldgraber, M. B. ; Rubin. C. E. ; Palmer, W. L. ; Dobson, 
R. L., and Massey, B. W. : The Early Gastric Response to 
Irradiation. A Serial Biopsy Study, Gastroenterol. 2 7 :l-20. 1954. 

12. Moss, W. T. : Therapeutic Radiology, The C. V. Mosby 
Co., St. Louis, 1959. 

13. Rider, J. A. ; Moeller, H. C. ; Althausen, T. L., and Sheline, 
G. E. : The Effect of X-Ray Therapy on Gastric Acidity and on 
17-Hydroxycorticoid and Uropepsin, Ann. Int. Med. 47 :651-665, 
1957. 

14. Carpender, J. W. J. ; Levin, E. ; Clayman, C. V., and 
Miller, R. E. : Radiation in the Therapy of Peptic Ulcer, Am. J. 
Roentgenol. 75 :374-379, 1956. 

15. Palmer, W. L., and Templeton, A. : The Effect of Radia- 
tion Therapy on Gastric Secretion, J.A.M.A. 112:1429-1434, 
1939. 

16. Levin, E. ; Clayman, C. V. ; Palmer, W. L., and Kirsner, 
J. B. : Observations on the Value of Gastric Irradiation in the 
Treatment of Duodenal Ulcer, Gastroenterol. 32 : 42-49, 1957. 

17. Brown, G., and Wood, I. J. : Antroduodenectomy and 

X-Ray Irradiation in the Treatment of Duodenal Ulcer, Aust. 
New Zea. J. Surg. 24:260-267, 1955. 

18. Kiefer, E. O., and Smedal, Magnus, J.: Radiation Therapy 
for Stomal Ulcer Occurring After Subtotal Gastrectomy, 
J.A.M.A. 169:447-451, 1959. 

19. Brown, C. H. ; Sahba, M., and Levin, E. : Irradiation With 
Cobalt 60 Teletherapy in the Treatment of Complicated Peptic 
Ulcer, Am. J. Gastroenterol. 38:278-289, 1962. 

20. Klien, H. C., and Berman, N. E. : Gastric Radiation — 
Nonsurgical Treatment for the Surgical Ulcers, J.A.M.A. 176: 
98-101. 1961. 

21. Reckling, W. E., and Eiseman, B. : Operative Experience 
Following Gastric Irradiation for Ulcer, Arch. Surg. 84:467- 
469, 1962. 


ADVERTISEMENTS 


301 


in virtually all diarrheas... prompt symptomatic control 


LOMOTIL 

TABLETS/ LIQUID— Each tablet and each 5 cc. of liquid contains: 
diphenoxylate hydrochloride ... 2.5 mg. 

(Warning: May be habit forming) 
atropine sulfate 0.025 mg. 



JL^omotil controls the basic physiologic dysfunction in diarrhea— exces- 
sive propulsive motility. Pharmacologic evidence indicates that it does 
so by directly inhibiting propulsive movements of the intestines. This 
direct, well-localized activity controls diarrheas of widely varied origin 
and does so promptly, conveniently and economically. 

The relatively few conditions in which Lomotil has given less than 
satisfactory control have been, for the most part, those such as severe 
ulcerative colitis in which too little anatomic or functional capacity 
of the intestines remains for the motility-lowering action of Lomotil 
to have effect. 

It should be noted, however, that Lomotil has proved highly useful 
in mild to moderate ulcerative colitis and in several other refractory 
forms of diarrhea. 


The recommended initial adult dosage is two tablets (2.5 mg. each) 
three or four times daily, reduced to meet the requirements of each 
patient as soon as the diarrhea is controlled. Maintenance dosage may 
be as low as two tablets daily. Children’s daily dosage (in divided doses) 
varies from 3 mg. for a child of 3 to 6 months to 10 mg. for one 8 to 
12 years of age. Lomotil is an exempt narcotic; its abuse liability is 
low and comparable to that of codeine. Recommended dosages should 
not be exceeded. Side effects are relatively uncommon but among those 
reported are gastrointestinal irritation, sedation, dizziness, cutaneous 
manifestations, restlessness and insomnia. Lomotil should be used with 
caution in patients with impaired liver function and in patients taking 
addicting drugs or barbiturates. Lomotil is a brand of diphenoxylate 
hydrochloride with atropine sulfate; the subtherapeutic amount of 
atropine is added to discourage deliberate overdosage. 

Research in the Service of Medicine 


SEARLE 




Leonard T. Furlow, M.D. 


President’s 

Message 


One of the first responsibilities of a newly in- 
stalled President of the Missouri State Medical 
Association is the appointment of members of 
committees. This was done at the 106th Annual 
Session. 

At this session, as at all sessions, it is quite 
obvious that the committees play an extremely 
important part in the affairs of the Association. 
At the Annual Session the House of Delegates 
receives reports from the committees and bases 
its actions on these reports. During the year when 
the Council acts as the executive body, it de- 
pends on the studies and reports of the various 
committees and often delays actions until it has 
received the advice of the committee. 

Therefore I hope that all members appointed 
to committees will accept the responsibility of 
serving and will realize that they, as members 
of committees, serve a basic need in the activities 
of the Association. Officers, Councilors and staff 
are always ready to assist in committee work. 




302 



EDITORIAL 


THE BUNDLE OF STICKS 

The well known fable of the man who could 
break the sticks separately but not as a bundle 
is becoming more and more pertinent to the 
field of medicine. To divide and conquer is one 
of the oldest military strategies. Unfortunately 
for health care there are many well intentioned 
but badly informed individuals who view the 
physician as a skilled health technician, but one 
who is incompetent in “social planning.” It is 
true that the physician is increasingly dependent 
upon other disciplines to render complete health 
care. It is equally true that he alone has the 
variety of educational and clinical exposures 
needed to create the necessary perspective for 
the solution of the complex health problems of 
today’s urban and rural populations. 

It is a sad but inevitable fact that success 
often brings more trials than does failure. Med- 
icine is in such a predicament. The intense dedi- 
cation of the members of the profession in Amer- 
ica was originally evidenced in the manner and 
basic principles upon which the AMA was 
founded in 1847. As a result of the concerns of 
organized medicine medical care improved, sci- 
entific endeavors became more productive and 
ancillary health personnel was added; in turn 
the American public became the recipients of 
the finest medical care which has ever existed. 
The public response, a natural one, was to find 
ways to give generous financial support to this 
valuable social resource through private and pub- 
lic sources. The resultant and rapid growth which 
was stimulated and in part directed by the sup- 
port of the donors has placed medical education 
and research in a difficult position. On the one 
hand it cannot avoid moving briskly forward in 
the design of education and research method- 
ology which will anticipate the needs of the 
future. On the other hand, forward movement 
in this area will be of no avail if educators can- 
not maintain adequate communication and rap- 


port with the physicians of today who perforce 
were educated in the past. As the discovery of 
new information hurtles onward this becomes 
an ever greater dilemma. Recent actions of the 
House of Delegates of the AMA and some med- 
ical societies in other states clearly depict the 
urgency of the situation. 

One simple fact remains. If the medical profes- 
sion, as we know it, is to survive at all it will be 
because of internal cohesiveness. If it splinters 
and falls prey to the many avaricious groups who 
covet the support, both financial and moral, 
which medicine now enjoys, we will have only 
ourselves to blame. 

The similarities of town and gown are far 
greater than the differences. Practitioners move 
easily into the role of full time teachers and the 
educators who are already giving patient care 
move quite as easily into private practice. Per- 
haps more of this should occur. It is essential that 
we base our every professional and social action 
upon the knowledge that the end point for edu- 
cator and practicing physician alike is the same 
—to improve the health of society at large. With- 
out schools there can be no educated profession, 
without the profession the school serves no use- 
ful purpose. 

It is time that we awaken to the divisive forces 
which threaten our unity. Only by understand- 
ing each other, including our mutual concerns 
and challenges, can we preserve the heritage of 
centuries which has been entrusted in our keep- 
ing. We possess the necessary capabilities and 
more to resolve the problem which faces us; only 
the necessary motivation is lacking. This task of 
resolving the differences cannot be left to “some- 
one else,” it is the prime responsibility of each 
person who proudly bears the M.D. degree and 
wishes to pass his profession on to his successors 
a little better than he received it. 

Vernon E. Wilson, M.D. 


303 


Ramblings of the Field Secretary 


On Tuesday night, February 4, the Chariton- 
Macon-Monroe-Randolph County Medical So- 
ciety promoted a project which may well be con- 
sidered by other medical societies. A dinner 
meeting was set up for some 36 ambulance peo- 



Dr. Rowlette and Dr. J. Will Fleming demonstrated 
a plastic bag splint. 


pie representing 12 ambulance companies who 
serve the four counties in handling accident vic- 
tims. This dinner meeting was held at the Wood- 
land Hospital in Moberly. Following a bountiful 



The audience was interested. 


•dinner, a special program on “Emergency Medi- 
cal Care for Ambulance Personnel” was present- 
ed by four members of the medical society. 

“Emergency Splinting of Fractures and Con- 
trol of Hemorrhage” was discussed by A. P. Row- 
lette, M.D. of Moberly. He demonstrated the 
use of a plastic bag which is blown up to serve 
ior splinting of fractures and control of hemor- 



Members of the audience tried mouth to mouth 
breathing technic. 


rhage. “Obstetrical Emergencies Outside the 
Hospital were discussed by Robert H. Young, 
M.D. of Moberly. “External Cardiac Resuscita- 
tion was explained and demonstrated by J. Will 
Fleming Jr., M.D. of Moberly. “Indications for 
Oxygen Therapy and Mouth to Mouth Breathing 



Drs. Young, Rowlette, J. Will Fleming and T. S. 
Fleming put on the program. 


Technic” were explained and demonstrated by 
Thomas S. Fleming, M.D. of Moberly. 

A plastic mannequin was effectively used in 
the demonstrations involving external cardiac 
resuscitation and mouth to mouth breathing tech- 
nic. Each member of the audience, with the co- 
operation of the mannequin, experimented with 
the technic of mouth to mouth breathing. The 
ambulance personnel present expressed their ap- 
preciation of this practical program of useful 
( Continued on page 308) 


304 






When you recognize signs of depression and 

anxiety and associate them with an 

organic condition— add 'Deprol' to your therapy. 

Typical conditions in which 'Deprol' should be considered 
for control of the associated depression and anxiet y: 

cardiovascular disorders ■ arthritis ■ cancer ■ menopause ■ alcoholism 

■ obesity ■ asthma, hay fever and related allergies ■ chronic infectious diseases 

■ dermatoses ■ G.l. disorders, and many other organic disturbances. 


When you recognize depression and anxiety 
traceable to an emotionally charged situation with 
no somatic disorder— start the patient on 'Deprol'. 

Typical situations in which 'Deprol' is indicated : 

fear of cancer or other life-threatening disease ■ pre- and post-operative fears 

■ postpartum despondency ■ family problems ■ death of a loved one ■ loss of work 

■ retirement problems ■ financial worries, and many other stressful situations. 




Deprol 

meprobamate 400 mg. + benactyzine hydrochloride 1 mg. 


BRIEF SUMMARY: Indications: Depression, especially 
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tion or insomnia. Side Effects: Slight drowsiness and, 
rarely, allergic reactions, due to meprobamate, and occa- 
sional dizziness or feeling of depersonalization in higher 
dosage, due to benactyzine, may occur. Meprobamate may 
increase effects of excessive alcohol. Use with care in 
patients with suicidal tendencies. Consider possibility of 
dependence, particularly in patients with history of drug 


or alcohol addiction. Withdraw gradually after prolonged 
use at high dosage. Complete product information avail- 
able in the product package, or to physicians upon 
request. 

USUAL ADULT DOSAGE: 1 tablet q.i.d. May be increased 
gradually, as needed, to 3 tablets q.i.d.; with establishment 
of relief, may be reduced gradually to maintenance levels. 

SUPPLIED: Light-pink, scored tablets. Bottles of 50. 


WALLACE LABORATORIES/ Cranbury, N. J. 


News — Personal and Professional 


Speaking on vocational training, Avery P. 
Rowlette, M.D., Moberly, addressed the Little 
Dixie Chapter of the American Business Wom- 
en’s Association at Moberly early in February. 


The Central Neighbors Club at Hannibal had 
James C. Steele Jr., M.D., Hannibal, as speaker 
at a meeting on February 3. 


Principal speaker at a meeting of the St. Jo- 
seph Chapter of the Order of DeMolay Febru- 
ary 10 was John N. Martin, M.D., St. Joseph. 


Participating in a panel discussion at a meet- 
ing of the American College of Surgeons in Den- 
ver February 17 was Ian M. Thompson, M.D., 
Columbia. 


Speaker at the January meeting of the Turner 
P.T.A., Hannibal, was Henry Sweets, M.D., 
Hannibal. 


Recently appointed as consultant in alcohol- 
ism for the State Division of Mental Diseases is 
Joseph B. Kendis, M.D., St. Louis. 


The fifteenth annual Dr. F. G. Thompson Sr. 
Lecture will be given on May 6 at the Thomp- 
son, Brumm & Knepper Clinic building, St. Jo- 
seph, by James C. White, M.D., Boston. 


Speaking at the Triological Society meeting at 
the Mayo Clinic, Rochester, Minn., in late Jan- 
uary John S. Knight, M.D., Kansas City, dis- 
cussed “Laryngeal Stenosis: Method of Surgical 
Correction.” 


The St. Joseph Rotary Club had as speaker at 
its February 4 meeting William H. Ames, M.D., 


St. Joseph, who discussed “Profile of a Cor- 
onary.” 


At a meeting of the American Academy of 
Orthopedic Surgeons recently Fred C. Reynolds, 
M.D., St. Louis, was named president-elect. 


Named “Boss of the Year Hugh E. Stephen- 
son Jr., M.D., Columbia, received a trophy at a 
meeting of the Columbia American Business 
Women’s Association. 


WOMAN’S AUXILIARY 

(Continued from page 270) 

ERF with the sale of playing cards and sympa- 
thy cards. Greene has an annual project of aid- 
ing the Tuberculosis Society’s yearly campaign. 
Perry, Cooper, Jefferson, Miller-Morgan-Moni- 
teau, South Central, Ozarks and West Central 
counties worked through local groups and hon- 
ored their men on Doctor’s Day. 

We ll hope the doctors see this article and 
beam with pride over the services their wives 
accomplish throughout the state. 


RAMBLINGS OF THE FIELD SECRETARY 

(Continued from page 304) 

technics helpful to them in their responsibilities 
for emergency medical care. 

At the conclusion of the formal program many 
questions were posed by the audience and the 
discussion continued far into the evening. 

It is understood that the American College of 
Surgeons has been interested in promoting ac- 
tual demonstrations of this nature but is appar- 
ently not constituted organizational wise to put 
on such programs as the county medical societies 
as demonstrated by the Chariton-Macon-Mon- 
roe-Randolph Society on February 4. It would 
seem that county medical societies seeking good 
sound really worthwhile public relations projects 
have an example here well worth their consider- 
ation. 


308 


PHYSICIANS’ INVESTMENT SERVICE 

A New Special Service for Busy Physicians 


Few doctors can devote sufficient time to the careful 
handling of their investments. For this reason, Edward 
D. Jones & Co., oldest brokerage firm west of the 
Mississippi, is now offering Missouri’s physicians an 
investment service designed to conserve their time 
and energy, make record-keeping for tax purposes 
easier, and provide them with experienced investment 
guidance. 

The Physicians’ Investment Service Department will 
perform the following services for each doctor client: 

1. Maintain custody of securities. 

2. Collect dividends and interest. 

■HHHjHpppi 

ANS . INVESTMENT SERVICE —NT 

JOHN DOE 

. rn MEMBERS 
Irk stock exchange 


3. Issue one check monthly or quarterly covering in- 
come from securities. 

4. Render a monthly statement showing any trans- 
actions in the account. 

5. Render a monthly portfolio recapitulation of security 
holdings showing for each security its cost, current 
market price, total value, change in value for the 
month, yield, and the estimated annual income derived 
from it. (See sample portfolio reproduced below.) 

6. Lend money for any purpose to clients who wish to 
make use of their listed securities as collateral. 


Poge 


Q \ portion Number 

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r — Art 12 s 

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L** 'S* 27 
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ON STOCKS 

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Established 1871 

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i i 7cnn 


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Please send me further information about this 
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Name. 





New Members 


A. Sherwood Baker, M.D., 807 Stadium Road, 
Columbia, has become a member of Boone 
County Medical Society. Dr. Baker is a native 
of Mount Morris, 111., received his preliminary 
education at Cornell College, and his M.D. de- 
gree at the University of Illinois in 1942. He 
specializes in general practice. 

J. W. Bernard, M.D., Doctors Clinic, Caruth- 
ersville, has become a member of Pemiscot 
County Medical Society. Dr. Bernard is a native 
of Memphis, Tenn., received his preliminary 
education at Southwestern at Memphis, and 
his M.D. degree at the University of Tennessee 
in 1959. He specializes in general practice. 

Elwyn S. Brown, M.D., 1710 Independence 
Road, Kansas City, has become a member of 
Jackson County Medical Society. Dr. Brown is 
a native of Belle Plaine, Iowa, received his pre- 
liminary education at State University of Iowa, 
and his M.D. degree at the University of Iowa 
in 1950. He specializes in anesthesia. 

Edwin K. Burford Jr., M.D., 937 Broadway, 
Cape Girardeau, has become a member of Cape 
Girardeau County Medical Society. Dr. Burford 
is a native of Doniphan, Mo., received his pre- 
liminary education at the University of Missouri, 
and his M.D. degree at Washington University 
in 1958. He specializes in general practice. 

John P. Crotty, M.D., 3244 January Ave., St. 
Louis, has become a member of St. Louis Medi- 
cal Society. Dr. Crotty is a native of St. Louis, 
received his preliminary education at Notre 
Dame and St. Louis University, and his M.D. 
degree at St. Louis University in 1962. 

Kenneth Dempsey, M.D., 2431 N. 49th St., 
Milwaukee, Wis., has become a member of St. 
Louis Medical Society. Dr. Dempsey is a native 
of St. Louis, received his preliminary education 
at St. Louis College of Pharmacy, and his M.D. 
degree at the University of Missouri in 1962. 

George R. Gay, M.D., 807 Stadium Road, Co- 
lumbia, has become a member of Boone County 
Medical Society. Dr. Gay is a native of St. Louis, 
received his preliminary education at Amherst 
College, and his M.D. degree at the University 
of Missouri in 1961. He specializes in anesthesia. 

310 


Hector F. Hoenig Jr., M.D., Bethany, has be- 
come a member of Grand River Medical Society. 
Dr. Hoenig is a native of Brainerd, Minn., re- 
ceived his preliminary education at St. John's 
College, and his M.D. degree at the University 
of N. Dakota in 1962. He specializes in general 
practice. 

David S. Jacobs, M.D., 4949 Rockhill Road, 
Kansas City, has become a member of Jackson 
County 7 Medical Society 7 . Dr. Jacobs is a native 
of Detroit, Mich., received his preliminary edu- 
cation at the University of Michigan, and his 
M.D. degree at the University of Michigan in 
1956. He specializes in pathology. 

Robert G. Laffoon, M.D., Illmo, has become 
a member of Cape Girardeau County 7 Medical 
Society. Dr. Laffoon is a native of Union Star, 
Mo., received his preliminary education at the 
University of Missouri, and his M.D. degree at 
the University of Missouri in 1960. He special- 
izes in general practice. 

Troy O. Morgan Jr., M.D., Albany, has be- 
come a member of Northwest Missouri Medical 
Society. Dr. Morgan is a native of Atlanta, Ga., 
received his preliminary education at the Uni- 
versity of Oklahoma and his M.D. degree at the 
University of Oklahoma in 1956. He specializes 
in general practice. 

Bernie Parsons, M.D., Albany, has become a 
member of Northwest Missouri Medical Society. 
Dr. Parsons is a native of Battiest, Okla., re- 
ceived his preliminary education at Oklahoma 
State University, and his M.D. degree at the 
University of Oklahoma in 1961. He specializes 
in general practice. 

Donald B. Peterson, M.D., State Hospital 
No. 1, Fulton, has become a member of Calla- 
way County Medical Society. Dr. Peterson is a 
native of Minneapolis, Minn., received his pre- 
liminary education at the University of Minne- 
sota, and his M.D. degree at the University of 
Minnesota. He specializes in psychiatry. 

L. A. Reeves, M.D., 807 Stadium Road, Co- 
lumbia, has become a member of Boone County- 
Medical Society. Dr. Reeves is a native of Leon, 


ADVERTISEMENTS 


311 



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312 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
April, 1964 


Iowa, received his preliminary education at 
Graceland College, and his M.D. degree at the 
University of Iowa in 1961, He specializes in 
obstetrics. 

Roy C. Sloan, M.D., Marshall State School, 
Marshall, has become a member of Saline County 
Medical Society. Dr. Sloan is a native of Lingle- 
ville, Tex., received his preliminary education at 
Texas and Oklahoma Universities, and his M.D. 
degree at Baylor University in 1932. He special- 
izes in psychiatry. 

John E. Somers, M.D., 807 Stadium Road, 
Columbia, has become a member of Boone 
County Medical Society. Dr. Somers is a native 
of East Tawas, Mich., received his preliminary 
education at the University of Michigan, and his 
M.D. degree at the University of Michigan in 
1957. He specializes in neurology. 

Thomas C. Sparkman, M.D., 210 Christine 
St., Cape Girardeau, has become a member of 
Cape Girardeau County Medical Society. Dr. 
Sparkman is a native of Poplar Bluff, received 
his preliminary education at Southeast Missouri 
State College, and his M.D. degree at Baylor 
University in 1962. He specializes in general 
practice. 

James W. Terry Jr., M.D., 219 E. Pacific St., 
Cape Girardeau, has become a member of Cape 
Girardeau County Medical Society. Dr. Terry 
is a native of St. Louis, received his preliminary 
education at Memphis State University, and 
his M.D. degree at the University of Tennessee 
in 1957. He specializes in urology. 

Paul J. Wagner, M.D., 2826 Main St., Kansas 
City, has become a member of Jackson County 
Medical Society. Dr. Wagner is a native of Kan- 
sas City, Kan., received his preliminary educa- 
tion at the University of Kansas, and his M.D. 
degree at the University of Kansas in 1960. He 
specializes in anesthesia. 

Herbert D. Weintraub, M.D., 807 Stadium 
Road, Columbia, has become a member of Boone 
County Medical Society. Dr. Weintraub is a na- 
tive of Cleveland, Ohio, received his preliminary 
education at Western Reserve University, and 
his M.D. degree at Western Reserve University 
in 1958. He specializes in radiology. 

Thomas J. Williams, M.D., Osceola, has be- 
come a member of West Central Missouri Med- 


ical Society. Dr. Williams is a native of Oak 
Park, 111., received his preliminary education at 
Kansas City University, and his M.D. degree at 
the University of Kansas in 1962. He specializes 
in general practice. 


DEATHS 

Riley, Ralph D., M.D., St. Louis, a graduate 
of Washington University, 1902; member of St. 
Louis Medical Society; aged 81; died January 2. 

Biggs, James B., M.D., Bowling Green, a grad- 
uate of Washington University, 1913; member of 
Pike County Medical Society; aged 74; died 
January 25. 

Blache, J. Owen, M.D., St. Louis, a graduate 
of Howard University, 1932; member of St. Louis 
Medical Society; aged 64; died February 4. 

Tribble, Robert E., M.D., Chaffee, a graduate 
of the University of Missouri, 1953; member of 
Semo County Medical Society; aged 36; died 
February 5. 

O’Brien, Leo A., M.D., Kansas City, a gradu- 
ate of the University of Iowa, 1925; member of 
Jackson County Medical Society; aged 66; died 
February 10. 

Greaves, Eli A., M.D., Kansas City, a graduate 
of the University Medical College of Kansas 
City, 1895; member of Jackson County Medical 
Society; aged 94; died February 15. 

Koenig, George H., M.D., St. Petersburg, Fla., 
a graduate of St. Louis University, 1917; member 
of St. Louis Medical Society; aged 71; died 
February 16. 

Spitzer, Ernest, M.D., St. Louis, a graduate of 
the University of Vienna, 1902; member of St. 
Louis County Medical Society; aged 88; died 
February 16. 

Doubek, John C. Sr., M.D., St. Louis, a grad- 
uate of St. Louis University, 1921; member of 
St. Louis Medical Society; aged 75; died Febru- 
ary 19. 

Powell, Carl A., M.D., St. Louis, a graduate of 
St. Louis University, 1913; member of St. Louis 
Medical Society; aged 78; died February 22. 



AVERAGE DIASTOLIC DROP 


*has been reported after use of HYDROMOX Quinethazone in recent studies of patients with 
various hypertensive diseases, including essentia! hypertension and hypertension associated 
with arteriosclerotic heart disease, obesity, and renal disease.'- 2 The treatment period in one 
study was eight weeks’ and in the other, twelve. 2 The lack of serious disturbances in serum elec- 
trolyte levels, particularly of potassium, was noteworthy and was considered a sufficiently im- 
portant factor in treatment value to give the drug a preferential status. 2 One to two 50 mg. tab- 
lets once daily is usually sufficient. 

ANTIHYPERTENSIVE DIURETIC HYDROMOX 

QUINETHAZONE-TABLETS 


1. Schwartz, M.: Office Evaluation of a New Diuretic in Patients with Hypertensive Diseases. Scientific Exhibit 
Presented at the Clinical Meeting of the American Medical Association, Los Angeles, Calif., Nov. 25-28, 1962. 

2. Steigmann, F., and Griffin, R.: Evaluation of Quinethazone, a New Diuretic. J. Amer. Geriat. Soc: 11:945 


(Oct.) 1963. 

INDICATED in hypertension with or without edema, 
and in all types of edema involving salt retention. 
May be helpful in some cases of lymphedema, idio- 
pathic edema and edema due to venous obstruction. 
SIDE EFFECTS: Skin rash (rare), gastrointestinal dis- 
turbances, weakness and dizziness, seldom so severe 


that drug should be stopped. Generally, the adverse 
effects, sometimes associated with the thiazide diu- 
retics are possible. Pre-existing electrolyte abnor- 
malities may be aggravated. 

CONTRAINDICATION: Anuria. 


LEDERLE LABORATORIES, A Division of AMERICAN CYANAMID COMPANY, Pearl River, New York 


County Society News 


FIRST DISTRICT 

JOSEPH L. FISHER, ST. JOSEPH, COUNCILOR 
Buchanan County Medical Society 

Sixty St. Joseph and Northwest Missouri phy- 
sicians attended the annual heart meeting of the 
Buchanan County Medical Society, the evening 
of February 5. A program on “Heart” followed 
a social period, dinner and business session of 
the Society. Dr. William B. Rost, president, pre- 
sided. 

Speaker for the scientific program was Dr. 
James G. Janney Jr., associate professor of in- 
ternal medicine and director of the Department 
of Cardiology at St. Louis University. The speak- 
er is a native of St. Joseph. Dr. Janney discussed 
“Common Cardiovascular Problems.” He talked 
on symptoms, treatment and prognosis of various 
types of coronary disease, hypertension and 
mitral stenosis. The program was under the 
auspices of the St. Joseph Heart Association. 
The speaker was introduced by Dr. Lucien W. 
Ide, secretary of the Missouri Heart Association. 

Irwin Rosenthal, M.D., Secretary 

Grand River Medical Society 

Forty-two members, wives and guests assem- 
bled at the Strand Hotel for the regular February 
meeting. 

Following dinner, Dr. Joseph Fisher of St. 
Joseph, Councilor of the First District, gave a 
brief report on upcoming business for the Dele- 
gate’s meeting at MSMA convention. The wives 
adjourned to their separate meeting while Dr. 
Ralph Duncan of the Duncan Clinic of Kansas 
City spoke to the doctors. He gave an interesting 
discussion of his experiences with the clinic’s 
work in treating alcoholics. 

During a brief business meeting it was unani- 
mously voted that Dr. Herbert Booth of Hamil- 
ton be given honorary status. Dr. Booth entered 
practice in 1915. 

Guests present included Miss Gelsinger, Di- 
vision of Health now at Bethany; Mrs. Whitten 
of Trenton; Dr. and Mrs. Joseph Fisher of St. 
Joseph; Dr. Ralph Duncan of Kansas City; and 
Dr. Szymanski of Moberly. 

Jack L. Yin yard, M.D., Secretary 


SECOND DISTRICT 

HARRY L. GREENE, HANNIBAL, COUNCILOR 

Chariton-Macon-Monroe-Randolph 
County Medical Society 

Robert T. Manning, M.D., Assistant Professor 
of Medicine and Biochemistry, University of 
Kansas Medical School, Kansas City, Kan., spoke 
at a dinner meeting of the Chariton-Macon- 
Monroe-Randolph County Medical Society on 
Thursday night, February 13. His subject was 
“Enzymes and Disease.” The meeting was held 
in the Woodland Hospital at Moberly. 

After an extensive discussion of this subject by 
the speaker the discussion was thrown open to 
the audience. Additional interesting information 
was brought out in the general discussion and 
completed a fine scientific program. 

During the business part of the meeting re- 
ports were given on the recent Sabin oral polio 
vaccination projects in the four counties with 
agreement by all as being quite successful. In 
addition to members, guests present were Dr. 
Leopold La Chance, Centralia; Mr. John Falletta, 
a KU Medical Student, and Dr. Manning. Mem- 
bers in attendance were as follows: Dr. G. C. 
Rice, Chariton County; Dr. Donald Eggleston 
and Dr. James Campbell, Macon County; Dr. F. 
A. Barnett, Monroe County; and Drs. A. P. Row- 
lette, J. Will Fleming Jr., T. S. Fleming, R. H. 
Young, W. D. Chute, C. C. Cohrs, Robert Has- 
son, P. V. Dreyer and C. C. Smith, Randolph 
County. 

J. Will Fleming, M.D., Secretary 

Marion-Ralls-Shelby County Medical Society 

A dinner meeting of the Marion-Ralls-Shelby 
County Medical Society was held at the Moose 
Club in Hannibal on Tuesday evening, February 
18. A social hour preceded dinner followed by 
the program. 

A. M. Evans, M.D., Chief of Internal Medicine 
at the Ellis Fischel State Cancer Hospital in Co- 
lumbia spoke to the group on “Chemotherapy of 
Cancer.” This was an interesting and informative 
presentation and produced a fine general discus- 
sion following the formal presentation. 

J. H. Walterscheid, M.D., Secretary 


314 


ADVERTISEMENTS 


315 



It happens, even to the best of machines. 

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they work and why. He can find — 
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The serviceman is nearby (42 loca- 
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When you buy an electrocardiograph, 
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8621 East 55th St., Fleming 3-2038 


316 


ORGANIZATION ACTIVITIES 


Missouri Medicine 
April, 1964 


FOURTH DISTRICT 

PAUL R. WHITENER, ST. LOUIS, COUNCILOR 
Lincoln-St. Charles County Medical Society 

More than 40 people including doctors and 
guests attended a dinner meeting of the Lincoln- 
St. Charles County Medical Society at the 
“Charlevoix Nursing Home” in St. Charles on 
Tuesday night, February 25. The evening festivi- 
ties began with a tour of this splendid nursing 
home followed by an enjoyable social hour and 
dinner. 

The scientific program for the evening con- 
sisted of a full explanation of the details of the 
Sabin Oral Polio Immunization Clinics for Lin- 
coln and St. Charles Counties to be held on 
March 15 and May 17, 1964. Numerous questions 
were posed and answered so that all members 
of the medical Society would be fully informed 
on this most important project. 

Representatives of Lederle were present to 
answer questions concerning their part in the 
clinics. The medical Society appreciated the 
privilege of inspecting this outstanding nursing 
home and was grateful for the hospitality ex- 
tended by the management. 

R. J. Fleming, M.D., Secretary 


SIXTH DISTRICT 

O. B. BARGER, HARRISONVILLE, COUNCILOR 
West Central Missouri Medical Society 

The February meeting of the West Central 
Missouri Medical Society was held at the Coun- 
try Club in Nevada, on Thursday, February 13. 
Total attendance, doctors and wives, was 28. 
There was a social hour followed by a dinner. 

The scientific program was presented by N. K. 
Mitra, M.D., Hickman Mills, Mo. The topic was 
“Heart Murmurs in Children: Selection of Cases 
for Referral for Diagnostic Procedures.” The dis- 
cussion by Dr. Mitra of the differential diagnoses 
between functional and organic murmurs and 
the discussion of the diagnosis and treatment of 
congenital heart diseases was not only most in- 
structive but was intensely interesting. 

Following the scientific session, a business 
meeting of the Society was held. The minutes of 
the January meeting were read and approved. 
The membership application of Dr. Thomas A. 
Williams of Osceola was presented by the Cre- 
dentials Committee with a recommendation for 
acceptance. On motion duly made and seconded. 


Dr. Williams was voted a junior membership in 
the Society. 

There was a brief discussion of the oral polio 
vaccine clinic and the general opinion was that 
this should be postponed until fall. The secretary 
reported on the correspondence received, par- 
ticularly that concerning the approaching annual 
meeting of the MSMA. The secretary asked for 
a liberal expense account to be used in maintain- 
ing an adequate hospitality suite at the MSMA 
meeting. This request was granted by unanimous 
vote of the Society. The Councilor, Dr. O. B. Bar- 
ger, reported briefly on some of the important 
matters to come before the House of Delegates 
at the annual meeting and urged that all dele- 
gates be present. It was also urged that members 
of the Society appear before the Reference Com- 
mittees to express their views on matters brought 
before the House of Delegates. 

The president, Dr. Carter Luter, commented 
on the fact that the March meeting of the West 
Central Missouri Medical Society would occur in 
the same week as the annual meeting of MSMA 
and suggested that the March meeting of the 
Society be omitted. There being no objections 
to this suggestion, he announced that the next 
meeting of the Society would be in April. 

There being no further business to come be- 
fore the meeting, on motion duly made and 
seconded, the meeting was adjourned. 

Roy W. Pearse Jr., M.D., Secretary 


EIGHTH DISTRICT 

DOYLE McCRAW, BOLIVAR, COUNCILOR 

Ozarks Medical Society 

Thirty people including doctors and their 
wives attended a dinner meeting of the Ozarks 



Dr. and Mrs. Hollweg and Dr. and Mrs. McCraw were 
special guests. 


ADVERTISEMENTS 


317 



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"FRESH UP' with SEVEN-UP! 







318 


ORGANIZATION ACTIVITIES 


Missouri Mudicine 
April, 1&64 



Waiting to be served, the group visited. 


Medical Society at the Sands Motel in Aurora 
on Tuesday evening, February 11. Following a 
pleasant social hour, a delicious steak dinner was 
served and all were then ready to hear the dis- 
tinguished speaker of the evening. 

Dr. Kenneth Hollweg, Kansas City, President 



There was concentrated attention to Dr. Hollweg’s talk. 


of the Missouri State Medical Association, gave 
the principal address of the evening and dis- 
cussed in a practical manner the organizational 
structure of the State Medical Association and 
the basic importance of the active functioning of 
the County Medical Society. He then discussed 
briefly how this organizational set-up fits into 
the AM A. 

Those present were pleased to have as guests, 


along with Dr. Hollweg and Mrs. Hollweg, Dr. 
Doyle McCraw of Bolivar, Councilor of the 
eighth district, and Mrs. McCraw, and Ray Mc- 
Intyre, Field Secretary of the MSN1A. In his 
brief remarks, Dr. McCraw urged that as many 
members of the Society as possible attend the 
March meeting of the MSMA in St. Louis. 

Paul B. Anderson, M.D., Secretary 


NINTH DISTRICT 

E. A. STRICKER, ST. JAMES, COUNCILOR 
Mid Missouri County Medical Society 

A dinner meeting of the Mid Missouri County 
Medical Society and the doctors’ wives was held 
at the New Colonial Village in Rolla on Thurs- 
day night, February 27. The evening festivities 
began with a social hour followed by dinner and 
then the program. 

The scientific speaker for the evening was Wil- 
liam G. Hemenway, M.D., Director of the De- 
partment of Ear, Nose and Throat at the Uni- 
versity of Missouri Medical School. His subject 
was, “What a General Practitioner Should Know 
About Recent Advances in the Management of 
Ear, Nose and Throat Problems.’’ This was a 
most interesting and practical discussion and 
generated numerous questions which followed 
Dr. Hemenway ’s formal presentation. 

M. K. Underwood, M.D., Secretary 


TENTH DISTRICT 

W. D. ENGLISH, CARDWELL, COUNCILOR 

Butler-Ripley- Wayne County 
Medical Society 

A dinner meeting of the Tri-County Medical 
Society was held at the Holiday Inn Restaurant, 
Tuesday night, February 25, in Poplar Bluff. 

The scientific program for the evening was 
presented by J. W. Tosh, M.D., of the Poplar 
Bluff Hospital staff. His subject was “The Sur- 
gical Aspects of the Diaphragmatic Hernia.” 

W. D. Robertson, M.D., Secretary 



The discharged 
mental patient . . . 
and Thorazine *' 

brand of chlorpromazine 

“ The average practitioner is quite capable of handling the vast majority of ex-institu- 
tionalized patients by regulation of medication , reassurance, manipulation of the en- 


vironment where necessary, and . . . other t 

The family physician must often assume respon- 
sibility for the discharged mental patient. Thora- 
zine (chlorpromazine, sk&f) can be a valuable 
adjunct to the continuing care of this patient, 
because it helps prevent relapses by insulating 
him from the impact of stressful experiences. 
For successful rehabilitation and prevention of 
rehospitalization, however, the former mental 
patient— and often his family— also needs the 
guidance and counsel of his physician. 

Many physicians are surprised by the high doses 
of Thorazine (chlorpromazine, SK&F) used in pa- 
tients released to their care from mental hospitals. 
This surprise may be expressed by a drastic re- 
duction in dosage “to play it safe”— with serious 
consequences for the patient. 

The successful maintenance of former mental pa- 
tients requires adequate, often “high” dosage, and 
often for prolonged periods of time. Fortunately, 
these dosages do not mean greater risks for the 


XS. Kline, N.S.: Postgrad. Med. 27 : 620 (May) 1960. 

patient. On the contrary, there is much less risk 
of serious side effects once a patient has become 
gradually accustomed to Thorazine (chlorproma- 
zine, SK&F) — regardless of dosage — over a period of 
a few months. Continuing therapy is almost 
always well tolerated, and is essential to most 
patients’ continued well-being. 

Brief Summary: Thorazine (chlorpromazine, sk&f) has been 
successfully used for 10 years in the treatment of mental and 
emotional disturbances, and has proven highly effective in 
the maintenance therapy of former hospitalized mental pa- 
tients. Principal side effects: The most frequently encountered 
side effect is transitory drowsiness. Other occasional side 
effects include: dry mouth, nasal congestion, constipation, 
miosis, dermatological reactions, photosensitivity, jaundice, 
hypotension, increased appetite and weight; very rarely, 
mydriasis, agranulocytosis, extrapyramidal symptoms. 
Contraindications: Comatose states or in the presence of 
excessive amounts of C.N.S. depressants. 

For complete prescribing information, please see PDR or 
available literature. 

Smith Kline & French Laboratories 



From the 
Medical Schools 



WASHINGTON UNIVERSITY 
Ear Bone Bank 

Washington University School of Medicine is 
one of 25 medical centers serving as Temporal 
Bone Banks in the United States. 

A nation-wide effort is now underway to se- 
cure the temporal ear bones after death of peo- 
ple who have had some form of deafness. The 
goal is to correlate medical history of deafness 
with lesions which appear on the bones. Ear 
bones of normal subjects are also being sought 
to aid in the training of surgeons specializing in 
diseases of the ear. The bones are used only for 
research and not as replacements as in other 
programs such as eye and vascular banks. 

“So little is known about why people are deaf,’ 
Dr. Theodore Walsh, Washington University’s 
coordinator of the program said. Dr. Walsh is 
professor and head of the department of oto- 
laryngology. 

“The ear is so inaccessible the only possible 
way to add to our knowledge is to study the 
bones after they are removed after death. By 
correlating what we see with the records of hear- 
ing tests and the patient’s past symptoms, we 
may better understand some of the causes of 
deafness,” he said. 

The Temporal Bone Bank program is spon- 
sored by the Deafness Research Foundation and 
the American Academy of Ophthalmology and 
Otolaryngology. Financial support for the Ear 
Bone Bank program has recently come from the 
John A. Hartford Foundation through the Acad- 
emy. 

Goal of the program is to help broaden knowl- 
edge of the pathology that accompanies such 
types of deafness as otosclerosis, sudden deaf- 
ness, congenital deafness, deafness following 
various childhood diseases, noise deafness, vas- 
cular disturbances and Meniere’s diseases. 

“We hope sometime to have a central repos- 
itory for the temporal bones where they will be 
available for study by all scientists,” Dr. Walsh 
said. “But this is not our current aim. Now we 
are trying to interest those who suffer from deaf- 
ness to provide us with the bones after death.” 

A person may indicate his wish to donate his 


ear bones by depositing a form with the Tem- 
poral Bone Bank headquarters in Chicago. The 
donor carries a card with him indicating that the 
center headquarters should be contacted at the 
time of his death. 

The bones must be removed immediately after 
death. This is done at no cost to the donor’s fam- 
ily and with no cosmetic disfigurement. The 
bones are then processed by the nearest ear bone 
center and made available for study. 

Further information on the Temporal Bone 
Bank may be obtained by writing Dr. Theodore 
Walsh, Washington University School of Medi- 
cine, St. Louis, Missouri 63110. 

Heart Association Grants 

The joint research committee of the Missouri 
and St. Louis Heart Association announced al- 
location of $80,584 to be used for study of heart 
and blood vessel diseases at medical schools in 
Missouri in the fiscal year beginning July 1. 

The money will be in the form of grants-in-aid 
and fellowships. Washington University will re- 
ceive $23,492 in the form of grants to Dr. Rich- 
ard M. Krause, Dr. Alexis F. Hartmann Jr. and 
Dr. James M. Stokes, and a fellowship to Dr. 
Pierre Doucet. 

This is the first year that the state and city 
associations have joined in the research program. 
Previously they made awards separately. The 
American Heart Association has not yet an- 
nounced grants for the St. Louis area. 

Coming Events 

Dr. J. D. Watson, Professor of Biology at Har- 
vard University and Nobel Laureate in Medicine 
and Physiology, will present the seventh annual 
Philip A. Shaffer Lecture on Monday, April 27 in 
Clopton Amphitheatre. He will speak on the role 
of ribosomes in protein synthesis. 

The Alpha Omega Alpha lecture will be pre- 
sented on April 30 by Dr. Sidney Goldring, as- 
sociate professor of neurological surgery. 

April 8 is the date of the annual Senior Re- 
search Assembly. Senior medical students who 
have done research during any of the four years 
of medical school are eligible to present their 
findings for faculty and other students. 



Volume 61 
Number 4 


MISCELLANY 


321 


Faculty Honors 

Dr. Margaret Smith, professor of pathology, 
received a faculty citation at the annual Foun- 
ders Day banquet February 22. Dr. Smith was a 
member of the pathology department at Johns 
Hopkins University from 1922 to 1929, at which 
time she joined the Washington University staff. 
Dr. Smith has done extensive research into the 
nature of encephalitis and salivary gland virus. 

Dr. Carl A. Moyer, Bixby Professor and head 
of the department of surgery, has been named 
chairman of the Medical Scientist Training Com- 
mittee which was recently established by the 
National Institute of General Medical Sciences, 
National Institutes of Health. 

Dr. Carl V. Moore, Busch Professor and head 
of the department of medicine, has been named 
a member of the newly formed Drug Research 
Board of the National Academy of Sciences. 

Dr. Meredith J. Payne, assistant in clinical sur- 
gery, was honored for professional achievement 
in the 1964 Bicentennial Salute to Women Who 
Work. 

UNIVERSITY OF MISSOURI 
Trips and Talks 

Dr. James A. Green, associate professor of 
anatomy at the University of Missouri Medical 
Center, spent February 14 to 16 at the Southwest 
Foundation for Research Education, San An- 
tonio, Tex. The purpose of the trip was to consult 
with his research collaborators, Dr. Joseph W. 
Goldzieher and Dr. Herman Acevedo concerning 
their joint research on ovaries from Stein-Leven- 
thal patients and their project studying the bio- 
chemistry and fine structure of normal human 
ovaries. 

Dr. J. M. Martt, associate professor of the De- 
partment of Medicine and head of the Heart Sta- 
tion, attended a meeting of the West Central 
Missouri Medical Society April 9 in El Dorado 
Springs. The topic of discussion was “Current 
Status of Serum Lipids and Coronary Athero- 
sclerosis.’ 

Dr. Martt; Dr. George Wakerlin, American 
Heart Association; Dr. J. C. Edwards, St. Louis; 
Dr. Charles F. Grabske, Kansas City, and Dr. 
James G. Janney Jr., St. Louis, were panelists at 
a meeting of the Missouri Heart Association May 
15 in Columbia. The topic of discussion was 
“Heart Attack.” Members of the Missouri Heart 
Association and heart volunteers attended the 
meeting. 

Dr. Frank B. Engley, professor and chairman 



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322 


MISCELLANY 


Missouri Medicine 
April, 1964 


of the Department of Microbiology at the Uni- 
versity of Missouri Medical Center, attended 
executive board meeting of the Missouri Public 
Health Association, in Jefferson City, January 30. 

Dr. Donald P. Durand, assistant professor of 
microbiology, presented a seminar covering the 
various aspects of virus-cell interactions at a 
meeting of the Department of Botany and Micro- 
biology at the University of Oklahoma on Febru- 
ary 6. About 30 professional people attended. 

Dr. Richard M. Hyde, assistant professor of 
microbiology, presided over a session in the 
Trauma Conference held by the University of 
Missouri Postgraduate Medical Education di- 
vision. The meeting was held on January 23 
through 25 at the Medical Auditorium in Colum- 
bia. Dr. Hyde also presented a seminar covering 
research on “Immunologic Tolerance to a Mix- 
ture of Antigens” at the University of Iowa De- 
partment of Microbiology on February 7. 

Dr. Fernando Tapia, chief of the section of 
Child Psychiatry at the University, led a short 
discussion period following a film entitled “If 
These Were Your Children.” The meeting was 
held at the Carousel Nursery School and was 
sponsored by the Carousel Nursery School As- 
sociation on February 6. 

Dr. Tapia was also on a panel which discussed 
the topic of psychotherapy and then answered 
questions at the Memorial Student Union on 
February 14. The University Counseling Service 
sponsored the meeting which was attended by 
approximately 60 graduate students. 

Dr. Kenneth Keown, professor and chief of 
the section of anesthesiology, was a guest speak- 
er at the Twenty-Sixth Annual Convention of 
the Mid-South Postgraduate Assembly of Nurse 
Anesthetists. The meeting was held February 13 
and 14 in Memphis, Tenn., and the topic of dis- 
cussion was “Premedication.” Dr. Keown was 
also the guest speaker at the January meeting 
of the Jasper County Medical Society, January 
14. The lecture was on “Heart Failure in the 
Operating Room.” 

Dr. G. W. Eggers Jr., associate professor of 
anesthesiology, attended a conference on “Hy- 
perbaric Oxygenation” in New York, February 
12 through 15. The meeting was sponsored by 
the New York Academy of Sciences and the Na- 
tional Academy of Sciences. 

Dr. John H. Landor, associate professor of 
surgery at the University of Missouri, was vis- 
iting professor of surgery at the University of 
Wisconsin School of Medicine. He gave two lec- 
tures and conducted teaching rounds on the sur- 
gical services. Phi Delta Epsilon medical fra- 
ternity sponsored the visit. 


Dr. Samuel P. W. Black, professor of surgery, 
attended the annual meeting of the Neurosur- 
gical Society of America held this year in Phoe- 
nix, Ariz., as the guest of Dr. George E. Roulhac 
of St. Louis. 

Dr. John A. Buesseler, professor and chief of 
ophthalmology, and Dr. Felix N. Sabates, as- 
sistant professor and associate chief of ophthal- 
mology, head, Retina Service, conducted sessions 
at the Postgraduate Medical Education Trauma 
Conference held January 23 through 25 at the 
Medical Center. Dr. Buesseler conducted a dis- 
cussion on “Physical and Chemical Injuries of 
the Eye”; Dr. Sabates conducted a discussion on 
“Internal Injuries of the Eye,” and together they 
conducted a discussion on the two topics. 

Dr. John W. Irvine, head, Lions Eye Tissue 
Bank at the University Medical Center, repre- 
senting the Lions Eye Tissue Bank of the Uni- 
versity of Missouri Medical Center was a witness 
in Jefferson City at the signing of a proclamation 
by Governor John A. Dalton of Missouri declar- 
ing February, 1964 as Eye Donor Month. 

Dr. William G. Hemenway, chief of the sec- 
tion of otolaryngology, was a visitor at the Uni- 
versity of Colorado Medical Center in Denver 
January 5 through 7. 

Dr. Owen J. Koeppe, who is on sabbatical 
leave, returned for a week’s visit. He gave a 
series of lectures on “Nucleic Acid Metabolism” 
for the first year medical students during his visit. 
Dr. Koeppe is taking his sabbatical leave at 
Tufts University at Boston, working under Dr. 
Meister. 

Dr. Thomas D. Luckey, chairman and profes- 
sor of the Department of Biochemistry; Arnold 
Smith, a fourth year medical student; Dr. James 
M. A. Weiss, professor and chairman of the De- 
partment of Psychiatry; Dr. Violet B. Matovich, 
assistant professor and chief of the section of 
neurology; Dr. Ernest E. McCoy, associate pro- 
fessor of pediatrics, and Dr. Robert L. Jackson, 
chairman and professor of the Department of 
Pediatrics, attended the Joseph P. Kennedy Jr. 
Foundation Awards Dinner in New York City, 
February 5. 

Visitors 

Dr. Seymour S. Cohen, professor of biochem- 
istry at the University of Pennsylvania School of 
Medicine, presented a lecture on February 6 at 
the University of Missouri School of Medicine 
entitled “Virus Induced Enzymes.” Dr. Cohen 
also gave a special seminar on February 7, en- 
titled “Sponges and D-arabinosyl Nucleosides.” 
Dr. Cohen was one of the special topics in bio- 
chemistry speakers scheduled for this year. 


Volume 61 
Number 4 


MISCELLANY 


323 


ELLIS FISCHEL STATE 
CANCER HOSPITAL 

Dr. John S. Spratt Jr., Chief Surgeon, Ellis 
Fischel State Cancer Hospital, was guest speaker 
at the Gastrointestinal Conference held Decem- 
ber 5, 1963, at Washington University School of 
Medicine. He was guest speaker and panelist at 
the Cleveland Clinic Educational Foundation on 
Colorectal Surgery in Children and Adults on 
January 7, 8 and 9, at which time he discussed 
“The Growth Rates of Neoplasms of the Colon 
and Rectum.” Dr. Galen B. Cook, Surgeon, also 
participated as panelist at the Cleveland Clinic 
Educational Foundation. 

Dr. Spratt discussed “Definitive Care in Ab- 
dominal Trauma” at the Trauma Conference held 
January 24 at the University of Missouri Medical 
Center. He participated in the Tumor Confer- 
ence, and lectured to the staff at St. John’s Hos- 
pital, St. Louis, February 11 and 12. On Febru- 
ary 14, he participated in the Tumor Conference 
held at the Yakima Medical Center, Yakima, 
Wash. On February 15 and 16, he was guest 
speaker at the Cancer Symposiums held in Rich- 
land and in Bellingham, Wash. These were spon- 
sored by the Washington Division of the Ameri- 
can Cancer Society. Dr. Spratt spoke on “The 
Rates and Growth of Cancers” on February 20 
at the Pemiscot County Medical Society. Dr. 
Spratt attended the Central Surgical Association 
in Rochester, Minn., February 27, 28 and 29, 
where he presented a paper, with Dr. Hiram C. 
Polk, entitled “Mortality After Operations for 
Colonic Cancer.” 

Dr. A. McChesney Evans, Chief of Internal 
Medicine at Ellis Fischel State Cancer Hospital, 
discussed the story behind the U. S. Surgeon 
General’s Advisory Committee Report on Smok- 
ing and Health at the Kiwanis Club, Columbia, 
February 4. He also spoke and showed slides on 
“Chemotherapy of Cancer” at a dinner meeting 
of the Marion-Ralls-Shelby County Medical So- 
ciety February 18, at the Moose Lodge, Hanni- 
bal. 

A week-long public health and institutional 
nurse orientation course was conducted Febru- 
ary 17 to 20 at the Ellis Fischel State Cancer 
Hospital. These programs on home care of cancer 
patients are regularly scheduled by the Missouri 
State Division of Health with the cooperation 
of personnel at Ellis Fischel Hospital. 

More than 60 patients of Ellis Fischel State 
Cancer Hospital were provided hair dressing 
service February 10 by the Columbia Cosmetol- 
ogist Association in celebration of the 14th An- 
nual National Beauty Salon Week. 


reduce 

or obviate 
the need for 

transfusions 
and their 
attendant 
dangers 



emostat 

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no report of an untoward reaction 
has been received ; however, 
it should be used 
with care on patients 

with a predisposition 



CHATHAM PHARMACEUTICALS, INC. 

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for a better blood 
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...for a better blood 
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rauwolfia side effects: 
Singoserp -Esidrix - 

(syrosingopine and hydrochlorothiazide CIBA) 


tter blood pressure 
ponse than with a 
azide alone 

dramatic potentiating 1 
potensive effect with 
client reductions in pres- 
'e was noted when syro- 
gopine [Singoserp] . . .was 
nbined with hydrochloro- 
azide [Esidrix].” 1 

wer thiazide dosage 
[ydrochlorothiazide 
sidrix] lowers the blood 
assure, and its antihyper- 
isive activity is poten- 
ited by syrosingopine 
ngoserp], allowing for a 
duction of the dose of 
iretic substance without a 
crease in control of the 
sease.” 2 

ss risk of 

uwolfia side effects 

'he combination of syro- 
igopine [Singoserp] and 
ydrochlorothiazide 
sidrix] not only has the 
potensive effects of reser- 
ne and hydrochlorothia- 
de but has the added 
vantage of causing fewer 
le-effects.” 3 


dications: Mild to moder- 
e hypertension, especially 
hen complicated by edema. 


Average Dosage: 1 Tablet #2 
(syrosingopine 1 mg. /hy- 
drochlorothiazide 25 mg.) 
t.i.d. For patients requiring 
less syrosingopine, substi- 
tute Tablet #1 (syrosingo- 
pine 0.5 mg. /hydrochloro- 
thiazide 25 mg.) . 

Side Effects & 
Precautionary Measures 

Singoserp (syrosingopine): 
Use cautiously in patients 
with peptic ulcer. Discon- 
tinue several weeks prior to 
surgery, if possible. 
Occasional side effect : nasal 
congestion. Rare side effects: 
gastric irritation, drowsi- 
ness, fatigue, nausea, head- 
ache, emotional depression, 
skin rash, restlessness, 
anxiety. 

Esidrix (hydrochlorothia- 
zide): Watch for signs of 
fluid or electrolyte imbal- 
ance. Further electrolyte 
depletion may cause hypo- 
chloremic alkalosis and 
hypokalemia. Since the lat- 
ter may precipitate digitalis 
intoxication, watch care- 
fully patients taking digi- 
talis or its glycosides. 

Pay special attention to 
electrolyte balance of pa- 
tients with severe renal or 
hepatic insufficiency. In 
patients with cirrhosis and 


ascites, watch for symptoms 
of impending hepatic coma. 
Contraindicated in patients 
with oliguria and complete 
renal shutdown. 

Rare reactions: purpura 
with or without thrombocy- 
topenia, skin rash, photo- 
sensitivity, urticaria. Thia- 
zides may decrease glucose 
tolerance ; use cautiously in 
diabetics. Hyperuricemia 
may occur but is readily 
reversed by a uricosuric 
agent. 

Occasional side effects: 
nitrogen retention (in hyper- 
tensive patients), nausea, 
anorexia, headache, restless- 
ness, constipation. 

Supplied 

Tablets # 2 (white), each con- 
taining 1 mg. syrosingopine 
and 25 mg. hydrochlorothia- 
zide; Tablets 41 (white), 
each containing 0.5 mg. syro- 
singopine and 25 mg. hydro- 
chlorothiazide. 

References 

1. Kolodny, A. L., and Dabo- 
lins, R. : Angiology 11 :180 
(June) 1960. 

2. Bare, W. W.: J. Amer. 
Geriat. Soc. 5:795 (Oct.) 
1960. 

3. Lisan, P., and Balaban, S. 
A. : J. Amer. Geriat. Soc. 
5:803 (Oct.) 1960. 


Singoserp®-Esidrix® 

(syrosingopine and hydrochlorothiazide CIBA) 


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326 


MISCELLANY 


Missouri Medicine 
April, 1964 


SAINT LOUIS UNIVERSITY 
Grants 

Grants-in-aid and fellowships totaling $29,482 
have been awarded the School of Medicine by 
the Missouri and St. Louis Heart Association 
Joint Research Committee, it has been announced 
by Dr. Theodore Cooper, vice chairman of the 
committee. Dr. Cooper is associate professor of 
surgery at St. Louis University and represents 
the St. Louis Association. One year allocations 
will begin July 1. 

Grants in the amount of $14,982 have been 
awarded to Dr. George C. Kaiser, assistant pro- 
fessor of surgery; Dr. Drummond H. Bowden, as- 
sociate professor of pathology, and Dr. Howard 
Yanof, assistant professor of physiology. Fellow- 
ships totaling $14,500 have been awarded to Dr. 
Phillip Carr, Dr. Bernard Swaykus and Dr. Vijay 
S. Hiremath, all of whom will become fellows in 
cardiology in July. 

The Department of Pharmacology of the St. 
Louis University School of Medicine has been 
awarded a new grant in the amount of $25,000 
by the National Science Foundation for the sup- 
port of a project directed by Dr. Harold L. 
Segal, associate professor of pharmacology. 

Under the grant, Dr. Segal is attempting to 
determine the sequence of amino acids of en- 
zymes at the particular site in the protein chain 
where catalytic action takes place. Amino acids 
form the chief structure of proteins. 

Enzymes are proteins capable of producing 
catalytic action and speed the rate of chemical 
action in the body. In order to understand the 
chemical mechanism by which enzymes carry out 
this catalytic function, it is necessary to under- 
stand the structure of enzymes. 

In his research, Dr. Segal will attempt to iso- 
late the segment of the protein change that con- 
tains this active site, and will try to determine 
the amino acid sequence in the small segment. 

Dr. Norman E. Melechen, associate professor 
of microbiology, has received a National Foun- 
dation-March of Dimes renewal grant of $26,- 
733 for the support of work dealing with latent 
infection by bacteriophages, kinds of viruses that 
invade bacteria. How viruses can remain hidden 
and harmless and then be triggered to infective 
and damaging action is being studied. 

Scholarships 

Scholarship awards totaling $6,710 were pre- 
sented to 11 medical students in January. Awards 
from anonymous sources in the amount of $3,- 
350 went to eight students. Scholarships from St. 
Louis University totaling $1,400 were awarded 
to three students. Other awards included a $1,000 
scholarship from Charles Pfizer and Company 


and a $960 scholarship known as the Levi and 
Peppe Wolfort scholarship. The latter award was 
founded by Mr. Sigmund Wolfort and Miss Clara 
Wolfort in memory of their parents. Scholarship 
recipients are members of the freshman, sopho- 
more and junior classes. 

In the News 

A Division of Child Psychiatry has been es- 
tablished at Cardinal Glennon Memorial Hos- 
pital under the direction of Dr. Robert Gorday, 
assistant professor of psychiatry at St. Louis Uni- 
versity School of Medicine and Child Psychiatrist 
at Cardinal Glennon Memorial Hospital for Chil- 
dren. 

Dr. Thomas F. Frawley, director of the de- 
partment of internal medicine, and Dr. Edward 
T. Auer, director of the department of neurology 
and psychiatry, became honorary members of the 
Phi Rho Chapter of the Phi Chi Medical Fra- 
ternity at the fraternity’s recent Founders Day 
banquet. Dr. Alrick B. Hertzman, director, de- 
partment of physiology, was master of cere- 
monies. 

Dr. Ronan O’Rahilly, director, department of 
anatomy, attended the National Institutes of 
Health conference on “Aseptic Necrosis of the 
Femoral Head” and was discussant of a paper 
on the development and structure of the upper 
end of the femur. He attended a National Acad- 
emy of Sciences meeting in Chicago on children’s 
prosthetic problems. 

Dr. Armand E. Brodeur, associate dean, was a 
program participant at the meeting of the Amer- 
ican College of Radiology held in February. He 
appeared before programs held in Phoenix and 
Tucson. 

Dr. William A. Altemeier, Christian R. Holmes 
Professor of Surgery and Chairman of the De- 
partment at the University of Cincinnati, is 
scheduled to deliver the annual Hanau W. Loeb 
Lecture at the School of Medicine on Tuesday, 
March 10. He will speak on “Some Interesting 
Studies of Bacteriodes Infections in Surgery.” 
The lecture is sponsored by the Phi Delta Ep- 
silon Medical Fraternity. 

Dr. Charles M. Pomerat, Director of Research, 
Pasadena Foundation for Medical Research, 
Pasadena, delivered the annual Alphonse M. 
Schwitalla lecture sponsored by Alpha Omega 
Alpha, honorary medical society, January 30. 

Dr. Pomerat spoke on “Recent Advances in 
the Use of Cell Cultures in Experimental Med- 
icine.” He delivered a second lecture before 
members of the medical faculty in Miller Hall, 
Firmin Desloge Hospital. It was entitled “Dy- 
namic Activity Associated with Neuronal Func- 
tion.” 


Contents for May 1964 

Scientific Articles: 

The Management of Polypoid Lesions of 
the Colon and Rectum, Francis J. Burns, 

M.D., St. Louis 353 

For Mental Status to Diagnosis, Robert E. 
Froelich, M.D., Columbia, and R. W. 
Froelich, M.D., Lebanon 355 

Special Articles: 

A New Mental Responsibility Law for Mis- 
souri, James N. Haddock, M.D.; Mr. Or- 
ville Richardson, and Mr. Joseph J. Si- 
mone, St. Louis 358 

Thermonuclear Survival: Civil Defense in 
Industry, Solomon Garb, M.D., Columbia 374 

Departmental Features: 

Washington 342 


Across Missouri 344 

Missouri Academy of General Practice . 346 

Woman’s Auxiliary 350 

President’s Message 380 

Editorial 381 

Ramblings of the Field Secretary . . . 382 

News— Personal and Professional . . . 384 

New Members 386 

Deaths 388 

County Society News 390 

From the Medical Schools 394 

Missouri Medicine in Review .... 412 


Information for Contributors 


Articles are accepted for publication on condi- 
tion that they are contributed solely to this jour- 
nal. Material appearing in Missouri Medicine is 
protected by copyright. Permission will be granted 
on request for reproduction in reputable publica- 
tions provided proper credit is given and author 
gives permission. 

Manuscripts should be typewritten, double 
spaced, and the original with one carbon copy sub- 
mitted. Retain another carbon copy for proofread- 
ing. Used manuscripts are not returned. School and 
hospital appointments of the author should ac- 
company the manuscript. It is desirable that a 
synopsis-abstract of approximately 135 words ac- 
company the manuscript. Bibliography should be 
arranged at the end of the article in the order in 
which the references are cited in the text. The 
reference should give name of author, title of ar- 
ticle, name of periodical, volume number, initial 
page number and year. Authors are responsible 
for bibliographic accuracy. Bibliography should 
be double spaced. 

Illustrations should be glossy prints or draw- 
ings in India ink on white paper. They should 


not be mounted and name of author and figure 
number should be penciled lightly on the backs. 
Legends should appear on a separate sheet. 
Colored illustrations will be used when suitable 
if author assumes the actual cost. 

Legal difficulties may arise from unauthorized 
use of names, initials or photographs in which in- 
dividuals can be identified. Permission should be 
secured from patient or legal guardian and signed 
duplicate or photostat submitted with such photo- 
graphs or identification. The Editor and Editorial 
Board assume no responsibility for the opinions 
and claims expressed in articles contributed by 
authors. If citation of an institution related to the 
article is made, approval of the chief of service 
should be given in a letter accompanying the 
article. 

Reprint order blanks will accompany proof, 
which will be sent to authors prior to publication. 

All material other than scientific should be re- 
ceived prior to the first of the month preceding 
month of publication. 

Please give notice of change of address at least 
one month in advance of the change, giving old 
and new addresses. 


341 



At a hearing on H.R. 10041, Hospital and 
Medical Facilities Amendments of 1964, before 
the House Interstate and Foreign Commerce 
Committee on March 12, AMA testimony was 
presented by Drs. Percy E. Hopkins, Chairman 
of the Board of Trustees; Francis C. Coleman, 
Chairman of the Council on Legislative Activi- 
ties, and Willard A. Wright, Chairman of the 
Council on Medical Service. 

In part, testimony of Dr. Wright was: 

It is our recommendation that the Hill-Burton 
program be continued. We agree that some of its 
objectives should be redefined and some changes 
made in the program in order to make it more ef- 
fective. 

We believe that, with few exceptions, the Hill- 
Burton Construction Program has been administered 
effectively and in the interest of the public; and 
while we further believe that the objectives of the 
original legislation have for the most part been 
achieved, we agree that with a shift in emphasis to- 
ward modernization, and some modifications in the 
existing program, continuation of Hill-Burton is 
warranted for a period of time. 

Our support of this type of legislation is long 
standing. The American Medical Association has on 
numerous occasions gone on record as appproving 
the principle of hospital construction by the use of 
grants-in-aid. In 1940, the AMA House of Dele- 
gates supported President Roosevelt’s plan for the 
construction of hospitals with federal funds, and in 
1945, endorsed the AMA Board of Trustees’ support 
of the original Hill-Burton bill, saying: 

“This action of the Board of Trustees is within 
the (AMA) program of constructive action toward 
improving the health of the American people.” 

On a number of occasions, AMA representatives 
have appeared before committees of congress to give 
the views of the Association with respect to legis- 
lative proposals to extend and to amend the Hill- 
Burton Act. We have been aware of our obligation 
to provide the Congress with information and ex- 
pert opinion which could add additional substance 
to its discussions and deliberations. And while we 


have, in the main, approved the Hill-Burton pro- 
gram, we have also from time to time offered what 
we have believed to be constructive criticism. We 
hope to do so again today. 

Specifically, the American Medical Association 
supports the principle of matching grants for the 
construction and modernization of hospitals. We 
further support what appears to be a shift in em- 
phasis toward grants for the modernization of hos- 
pital and related facilities, the combining of cate- 
gorical grants, and the principle of federal support 
of construction through guaranteed mortgages. In 
these areas and in others, we support H.R. 10041. 
However, we shall note also where amendment to 
the provisions of H.R. 10041 would, in our opinion, 
establish a more effective program. 

We believe that the immediate and major em- 
phasis of Hill-Burton should be directed toward the 
improvement and effective use of existing facilities. 
It appears to us that the greatest need is for mod- 
ernization and renovation programs. 

According to the state Hill-Burton agencies, as of 
Jan. 1, 1963, there were 338,170 unacceptable beds 
which represented approximately 19 per cent of 
existing beds. Between 1957 and 1963, the number 
of inpatient beds increased from 1,505,695 to 1,786,- 
461 — an increase of 19 per cent. During this same 
period, the number of unacceptable beds, according 
to the state Hill-Burton agencies, increased from 
285,149 to 338,170 — also an increase of 19 per 
cent. Accordingly, in spite of construction during 
this period of time, the percentage of existing beds 
which are unacceptable remained the same. 

Another study, in 1956 by the American Hos- 
pital Association, indicated that almost one half 
(48 per cent) of all hospitals in the country needed 
some form of modernization of existing buildings 
at an estimated total cost of about $1 billion. Ap- 
proximately 80 per cent of the responding hospitals 
reporting a need for modernization stated that 
major repairs were needed in buildings and plants 
at an average cost of $126,000 per hospital. Ap- 
proximately the same proportion of hospitals re- 
ported a need for modernization of their equipment 
and mechanical systems, averaging $99,000 per hos- 
pital. Finally, one more study, in 1960 sponsored 
by the Public Health Service in cooperation with 
the state Hill-Burton agencies, indicated that it 
would cost $3.6 billion to modernize or replace ob- 
solete facilities without adding additional beds. 

The conclusion that the need is for renovation 
and modernization appears justified in the light of 
these statistics. . . . 


342 



• • • 


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with impaired cardiac or renal function should be 
observed because of the possibility of sodium and 
water retention. Liver function tests may reveal an 
increase in BSP retention, particularly in elderly 

The therapeutic value of anabolic agents depends on the ratio of 
anabolic potency to androgenic effect. This anabolic-androgenic 
activity ratio of Winstrol is greater than that of all the oral anabolic 
agents currently in use. 


patients, in which case therapy should be discon- 
tinued. Although it has been used in patients with 
cancer of the prostate, its mild androgenic activity 
is considered by some investigators to be a 
contraindication. 

Dosage in adults, usually 7 tablet t.i.d.; young wo- 
men, 7 tablet b.i.d.; children (school age), up to 7 
tablet t.i.d.; children (pre-school age), V 2 tablet b.i.d. 
Shows best results when administered with a high 
protein diet. Available as scored tablets of 2 mg. in 
bottles of TOO. 



Winthrop Laboratories, New York, N. Y. 






Dispensing Drugs Under Kerr-Mills 

Attorney General Eagleton ruled that physi- 
cians dispensing drugs to patients may be reim- 
bursed for the basic cost of the drug plus $1.00 
handling charge per prescription. He had been 
asked for such a ruling by the Division of Wel- 
fare. The ruling follows: 

This is in answer to your letter requesting an 
opinion of this office as to whether or not the pur- 
chase of drugs and medicines from a physician and 
payment of a $1.00 handling charge falls within the 
prohibition against the payment of “physician’s 
fees” in Subsection 6 of Section 208.150, RSMo 
Cum. Supp. 1963. 

The subsection reads as follows: “Any individual 
entitled to receive care or services under this sec- 
tion may obtain such care and services from any 
provider of services with which an agreement is in 
effect under this section and which undertakes to 
provide him such care and services, as authorized 
by the Division of Welfare.” 

This subsection prohibits the payment of the “at- 
tending physician’s fees.” However, there is no pro- 
hibition of the payment of charges for physician’s 
services. The limiting language used in the statute 
of “physician’s fees” shows a legislative intent to 
prohibit only the payment of the doctor’s profes- 
sional examination and attendance charges. This 


language likewise shows an intent to exclude from 
its orbit the dispensing of drugs which the doctor 
may decide to prescribe or may direct the patient 
to procure. Indeed, the filling of his own prescrip- 
tions is a distinct service that may be performed by 
the physician as provided for by Section 238.010, 
RSMo 1959. 

Therefore, it is the opinion of this office that the 
cost of drugs, together with a nominal handling 
charge of $1.00 paid to an attending physician who 
dispenses his own drugs, is not to be considered 
“physician’s fees” as that term is used in Subsection 
6 of Section 208.150, RSMo Cum. Supp. 1963. 

Missouri’s aging welfare recipients suffering 
from certain diseases were eligible, effective Oct. 
13, 1963, to receive certain drugs free of charge. 

On April 1, the list of drugs was expanded to 
include aging individuals on relief, suffering 
from respiratory ailments, pain and mental dis- 
eases. 

This service is part of the $10,000,000 health 
care for the aging program voted by the state 
legislature implementing provisions of the Kerr- 
Mills Act. Of this total appropriation $3,200,000 
was designated for drugs. 

The law authorizes the Director of Welfare 
and an advisory board to increase or reduce the 
drug benefits according to legal appropriation of 
funds. This control is necessary to prevent def- 
icit budget operation, which is illegal in Mis- 
souri. 

Registered Physicians in Missouri 

As of July 1, 1963, there were 5,955 physicians 
registered and living in Missouri. Of these 4,794 
were M.D.’s and 1,161 were D.O.’s. 

In an article in The Health Herald of the Di- 
vision of Health, it was said that every county 
in the state has at least one registered physician. 
All but six counties had M.D.’s and all but two 
counties has registered D.O.’s. 

The population-physician ratio was 748 people 
to each registered physician living in Missouri. 

More than half of the physicians registered 
with the Board of Healing Arts gave out-of-state 
addresses on their applications for registration. 


344 


ADVERTISEMENTS 


345 


The 

clear 

conclusion 
from 
10 years’ 
experience... 



belongs in every practice 

Miltown 

(meprobamate) 

WALLACE LABORATORIES/Cranbury, N. J. 


C. G. STAUFFACHER, M.D., Secretary 


Missouri Academy of General Practice 


The Ninth Annual Spring Clinical Conference 
of the University of Missouri School of Medicine 
will be held at the Medical Center on Wednes- 
day and Thursday, May 20 and 21. An excellent 
program has been developed and should be of 
much interest. The Wednesday morning, May 
20, session will be devoted to “Cardiology”; the 
afternoon session to “Endocrinology.” The Thurs- 
day morning, May 21, program will be concerned 
with “Psychiatric Emergencies in Medical Prac- 
tice”; and the afternoon session will be on “Gas- 
troenterology.” Both instate and outstate speak- 
ers will appear on this two day conference. This 
program is acceptable for 11 accredited hours bv 
the AAGP. 

It is anticipated that a good number of Acad- 
emy members over the entire state will be pres- 
ent to profit from this attractive program. 

Again this year on the first day of the spring 
clinical conference, a luncheon meeting for the 


junior medical students will be held in the Stu- 
dent Union Building sponsored by the Public 
and Professional Relations Committee of the 
MAGP and the Committee on Rural Medical 
Service of the MSMA. This has become an an- 
nual affair and seems to be a well accepted proj- 
ect by the medical students. Following the lunch- 
eon there will be short talks on solo practice, 
partnership practice and group practice with an 
opportunity given to students to ask questions 
of those on the panel. In addition, the President 
of the MAGP and the President of the MSMA 
will present short talks pertaining to the pro- 
grams of these two organizations. 

The Board of Directors of the MAGP will hold 
its annual spring meeting on Wednesday night, 
May 20, at the close of the first day’s session of 
the MU Spring Clinical Conference. The board 
will meet at the Daniel Boone Hotel in Columbia 
beginning at 6:00 p.m. 



Give now . . . 

to your 

medical student 
loan fund 
Help deserving 
young Missourians! 


Missouri State Medical Foundation 

634 Missouri Theatre Bldg. / Saint L^uis 3, Missouri 
SPONSORED BY THE MISSOURI STATE MEDICAL ASSN. 


346 


Better blood pressure 
response than with a 
thiazide alone 

“A dramatic potentiating’ 
hypotensive effect with 
excellent reductions in pres- 
sure was noted when syro- 
singopine [Singoserp] . . .was 
combined with hydrochloro- 
thiazide [Esidrix].” 1 

Lower thiazide dosage 
“Hydrochlorothiazide 
[Esidrix] lowers the blood 
pressure, and its antihyper- 
tensive activity is poten- 
tiated by syrosingopine 
[Singoserp], allowing for a 
reduction of the dose of 
diuretic substance without a 
decrease in control of the 
disease . ,,2 

Less risk of 
rauwolfia side effects 

“The combination of syro- 
singopine [Singoserp] and 
hydrochlorothiazide 
[Esidrix] not only has the 
hypotensive effects of reser- 
pine and hydrochlorothia- 
zide but has the added 
advantage of causing fewer 
side-effects.” 3 


Indications: Mild to moder- 
ate hypertension, especially 
when complicated by edema. 


Average Dosage: 1 Tablet #2 
(syrosingopine 1 mg. /hy- 
drochlorothiazide 25 mg.) 
t.i.d. For patients requiring 
less syrosingopine, substi- 
tute Tablet #1 (syrosingo- 
pine 0.5 mg. /hydrochloro- 
thiazide 25 mg.). 

Side Effects & 
Precautionary Measures 

Singoserp ( syrosingopine ): 
Use cautiously in patients 
with peptic ulcer. Discon- 
tinue several weeks prior to 
surgery, if possible. 
Occasional side effect : nasal 
congestion. Rare side effects: 
gastric irritation, drowsi- 
ness, fatigue, nausea, head- 
ache, emotional depression, 
skin rash, restlessness, 
anxiety. 

Esidrix (hydrochlorothia- 
zide): Watch for signs of 
fluid or electrolyte imbal- 
ance. Further electrolyte 
depletion may cause hypo- 
chloremic alkalosis and 
hypokalemia. Since the lat- 
ter may precipitate digitalis 
intoxication, watch care- 
fully patients taking digi- 
talis or its glycosides. 

Pay special attention to 
electrolyte balance of pa- 
tients with severe renal or 
hepatic insufficiency. In 
patients with cirrhosis and 


ascites, watch for symptoms 
of impending hepatic coma. 
Contraindicated in patients 
with oliguria and complete 
renal shutdown. 

Rare reactions : purpura 
with or without thrombocy- 
topenia, skin rash, photo- 
sensitivity, urticaria. Thia- 
zides may decrease glucose 
tolerance ; use cautiously in 
diabetics. Hyperuricemia 
may occur but is readily 
reversed by a uricosuric 
agent. 

Occasional side effects: 
nitrogen retention (in hyper- 
tensive patients), nausea, 
anorexia, headache, restless- 
ness, constipation. 

Supplied 

Tablets # 2 (white), each con- 
taining 1 mg. syrosingopine 
and 25 mg. hydrochlorothia- 
zide; Tablets # 1 (white), 
each containing 0.5 mg. syro- 
singopine and 25 mg. hydro- 
chlorothiazide. 

References 

1. Kolodny, A. L., and Dabo- 
lins, R. : Angiology 1 1 :180 
(June) 1960. 

2. Bare, W. W. : J. Amer. 
Geriat. Soc. 5:795 (Oct.) 
1960. 

3. Lisan, P., and Balaban, S. 
A. : J. Amer. Geriat. Soc. 
5:803 (Oct.) 1960. 


Singoserp’-Esidrix® 

(syrosingopine and hydrochlorothiazide CIBA) 


C I B A Summit, N.J. 


2/3181MK 


Woman’s Auxiliary 



We have just completed our 39th Annual Con- 
vention and it was indeed an attractive affair due 
to the fine efforts of Doris Cannon, Convention 
Chairman; Virginia Haynes, President of the St. 
Louis City Auxiliary; Helen Sanders who steered 
a fine river boat party on Sunday evening and 
of all the people involved in these committees; 
it was fun and our thanks to all of you. 

Again the gavel has changed hands as I ac- 
cepted it from Jane Crispell who has coached 
me in the knowledge of the 
many responsibilities in- 
volved in taking this sym- 
bol of order. 

Venus Schattyn, beloved 
past president (’62-’63) in- 
stalled the officers whose 
aid it will be my good for- 
tune to have in the coming 
year: Mrs. Ralph Bohnsack, 
president-elect; Mrs. James 
K. Ritterbusch, Mrs. Mau- 
rice A. Diehr, Mrs. Glenn 
O. Turner, Mrs. Robert H. Stewart, the four 
vice presidents; Mrs. C. Stuart Exon, recording 
secretary; Mrs. John M. Williams, treasurer; Mrs. 
James A. Reid, auditor; Mrs. Thomas Thale, cor- 
responding secretary and Mrs. Oliver E. Tjoflat, 
parliamentarian. 

The coveted gold cup donated by Dr. and Mrs. 
Charles T. Shepherd for the most outstanding 
auxiliary of the year went to the Grand River 
Auxiliary and Marty Vandiver, president, proud- 
ly accepted this award. In past years the cup 
has been won by the following counties: Cole, 
1955-56; Pettis, 1957; Jasper, 1958-59; St. Louis 
County, 1960 and Jackson, 1963. A special award 
was given the St. Louis City Auxiliary for the 
largest increase in donations to the AMA-ERF 
Loan Program. 

We had three honored guests with us; lovely 
Mrs. C. Rodney Stoltz our national president at- 
tended all our meetings and was an impressive 
speaker at the Monday luncheon held at the 
Three Fountains in Gaslight Square. Mrs. Paul 


Gray, President of the Southern Medical Auxil- 
iary battled the miserable weather to be with 
us at Tuesday’s luncheon. She added much to 
the proceedings and extended her personal in- 
vitation to all of us to attend their convention in 
Memphis this fall, November 16 to 19 when Mis- 
souri’s Ruth Kelling will be installed as presi- 
dent. Mrs. Willard Scrivner, president-elect of 
the Illinois Auxiliary was with us for all of our 
sessions and we were sorry that Illinois’s Presi- 
dent could not come with her and that the rep- 
resentatives of Kentucky’s Auxiliary were unable 
to attend. It was nice to have these special guests 
at our annual meeting. 

The Fifth and Sixth Districts have graciously 
offered to be our hostesses for the Fall Confer- 
ence and Board meeting on October 28 and 29 
at beautiful Tan-Tar-A Resort at Osage Beach. 
This is the prettiest time of the year in Missouri 
and a good time to urge your husband to do 
some fishing or relaxing; do plan to bring him 
along. 

Many fine reports were given on county 7 ac- 
tivities for the year at your business meetings 
and some of the resolutions presented and passed 
were: that we continue to support “Operation 
Hometown” in every way possible; that we con- 
tinue to encourage membership in unorganized 
counties through members-at-large and assist 
that chairman where possible; that in the in- 
terest of future memberships, we promote con- 
tact with and recognition to WASAMA (Med- 
ical Students’ Wives) organizations; that we en- 
list support from the MSMA and county 7 medical 
societies to encourage membership of wives in 
auxiliary and that “we explore” the degree of 
success of areas where the doctors automatically 
pay the state and national dues of their wives 
along with their own dues. 

As you see we are interested in increasing our 
membership. We would love to see the dream 
come true of every doctor’s wife as an Auxiliary 7 
member. Think what we could accomplish in 
our communities under such circumstances. 



Mrs. Delevan Calkins 


350 


Volume 61, Number 5 — May, 1964 


Missouri Medicine 

JOURNAL OF THE MISSOURI STATE MEDICAL ASSOCIATION 

Copyright, 1964 by Missouri State Medical Association. All Rights Reserved. 


FRANCIS J. BURNS, M.D., St. Louis 

The Management of Polypoid Lesions 
Of the Colon and Rectum 


A series of 703 patients with polypoid 
lesions of the rectum or colon or both is 
presented with report of the results and the 
methods of treatment used. 

Dr. Burns is Associate Professor of Clin- 
ical Surgery, St. Louis University School 
of Medicine. 


A rather common lesion of the rectum or colon 
that frequently demands attention is the “polyp.” 
This is generally meant to indicate an adenoma, 
or papilloma, but Morson 1 believes, and rightly 
so, that the term “polyp” is used too loosely. 
After all, the word “polyp” is purely descriptive, 
and one should specify just what type of polyp 
is under discussion. 

For the purpose of this presentation, the poly- 
poid lesions mentioned are mostly adenomata 
and papillomata. Other types, such as the ham- 
artomas, the inflammatory familial polyposis and 
pneumatoides intestinalis cystica are not in- 
cluded. 

In a personal series of 703 patients with poly- 
poid lesions of the rectum and/or colon, there 
were 409 males and 294 females. The average 
age was 52 years. The youngest was 2 years of 
age, the oldest 87. 

Signs and symptoms were present in 120 pa- 

1. Morson B. C. : Precancerous Lesions of the Colon and Rec- 
tum, J.A.M.A. 179 (Feb. 3) 1962. 


tients (17 per cent). In order of frequency, the 
most common signs and symptoms were bleed- 
ing, the production of mucus, protrusion through 
the anal orifice and change of bowel habits. 

The number of lesions encountered in these 
703 patients was 1,348. In 528 patients, only one 
tumor was found, and 175 patients had more 
than one tumor. In this latter group the number 
varied from two to 55. 

The majority of the tumors were small, and 
the broadest surface measurement was between 
0.5 centimeters and 5 centimeters though there 
were two patients with 10 centimeter lesions. 

The diagnoses were established by the usual 
methods for examination of the rectum and 
colon. The most important of these were palpa- 
tion with the examining finger, visualization via 
an endoscope and roentgenologic studies. The 10 
inch sigmoidoscope was the most useful instru- 
ment, but a 14 inch instrument was often used. 
In every instance in which a tumor was discov- 
ered, a contrast barium enema with x-ray was 
ordered. Because the majority of these lesions 
occur in the lower aspect of the colon and in the 
rectum, they can be palpated by the examining 
finger or visualized with an instrument. When 
such a lesion is found by palpation, especially 
if it is pedunculated, one should not attempt to 
pull it through the anal orifice because of the 
danger of avulsion from its pedicle, with result- 
ant bleeding. It is better to insert an instrument 


353 


354 


POLYPOID LESIONS— BURNS 


Missoubi Medicine 
May, 1964 


and visualize the tumor, or at least to wait until 
the patient is in the operating room of a hospital. 

Of the 1,348 lesions in this group of patients, 
1,147 were visualized with a sigmoidoscope, and 
191 lesions were discovered by means of roent- 
genologic studies of the colon, palpation of the 
colon at time of operation and colonoscopy at 
time of operation. The remaining 10 occurred 
on a colostomy stoma. The various segments of 
the colon harboring polypoid lesions, and their 
number are as follows: upper pelvic colon, 69; 
descending colon, 48; transverse colon, 45; as- 
cending colon, 13, and cecum, nine. 

Not every lesion was submitted for tissue 
diagnosis. Many were small in size, presumed to 
be benign on gross inspection, and were de- 
stroyed in situ by electro-desiccation. However, 
a tissue diagnosis was made in 281 patients. Of 
these, 181 were adenomata, 28 papillomata, and 
microscopic evidence of malignancy was found 
in 51 others. In addition, there were 16 cases of 
adenocarcinoma, four of carcinoid tumors and 
one of melanoma. Thus 68 patients (9 per cent) 
had evidence of malignancy, varying from a 
localized microscopic degree to a “full blown” 
carcinoma. 

The various methods of treatment and the 
number of tumors treated were: electro-desicca- 
tion, 771; excised with snare, 163; colotomy with 
polypectomy, 34, and colon resection, 53; ex- 
cised with associated carcinoma, 90 (colon re- 
section and/or abdomino-perineal resection); 
excised with anorectal operation, 46; local ex- 
cision, 27; procto-sigmoidectomy, four (abdom- 
ino-perineal “pull through”); passed with enema, 
two and not treated, 75. 

Because the majority of the lesions were so 
accessible, they were either eradicated in situ 
using electro-desiccation via a sigmoidoscope, or 
excised by means of a snare with electro-desic- 
cation of the base of the tumor. 

The snare is the most efficient instrument for 
the removal of pedunculated tumors. 

Usually a biopsy was not made, but the entire 
tumor was submitted as a specimen. In the case 
of larger tumors, biopsies were made from sev- 
eral different areas prior to definitive treatment 
of the tumor. 

Colotomy with polypectomy is not done as fre- 
quently in later years as a segmental colon re- 
section. The risk seems to be no greater and 
there is no added morbidity with resection. 
Colonoscopy is carried out as a routine proce- 
dure for polypoid colonic lesions, and is a re- 
warding maneuver. Many tumors were discov- 


ered in this fashion that could not be diagnosed 
otherwise. Generally two colotomy openings are 
made, one in the transverse colon and one in the 
pelvic colon. Occasionally, a colotomy is made 
also at the base of the cecum. 

Local excision was used for tumors in the rec- 
tum, and this included a posterior proctotomy 
approach, which was carried out in five in- 
stances. Sphincter function was unimpaired after 
division and reapproximation of the musculature 
in this operation. 

An abdomino-perineal “pull through” operation 
was performed in four patients, all with large 
papillomata of the rectum, the so-called villous 
tumors. 

No treatment was carried out in 75 patients, 
either because they went elsewhere, refused 
treatment or for various other reasons. 

The only complication that developed was 
postoperative bleeding, and this occurred in 
three patients. It ceased spontaneously in every 
case, and blood replacement was necessary only 
one time. There was no morbidity and only one 
death. The patient with melanoma of the rectum 
died six months after an abdomino-perineal re- 
section. 

Recurrence of the tumor was found in three 
patients, and in 44 patients (6 per cent), more 
tumors developed at a later date. 

After treatment, reexamination is made in one 
month, then at six month intervals for two years, 
then at 12 month intervals thereafter. A colon 
x-ray is advised every two years. 

Summary 

Polypoid lesions of the colon and rectum oc- 
cur rather frequently. The majority of such le- 
sions are readily accessible for treatment via the 
sigmoidoscope, and as such can be taken care of 
in the office or on an outpatient basis in a hos- 
pital. 

A variety of methods of treatment is available, 
depending upon the size and location of the le- 
sion, and various other factors. These are out- 
lined and briefly discussed. 

In this particular series of 703 patients with 
polypoid lesions of the colon or rectum, 68 pa- 
tients (9.6 per cent) had some degree of malig- 
nancy, and in 44 patients (6 per cent), more 
tumors developed at a later date. 

The complications were few, there was no 
morbidity' and only one death (a patient with 
melanoma of the rectum ) . 


ROBERT E. FROELICH, M.D., Columbia , and 
R. W. FROELICH, M.D., Lebanon 


From Mental Status to Diagnosis 


“A Look at the Forests Rather 
Than the Trees” 

The multiplicity of individual psychiatric diag- 
noses with their subtle differences about which 
psychiatrists themselves may disagree, has led 
to an avoidance of psychiatric diagnoses by the 
practicing physician. There is, however, an ab- 
breviated mental status examination which will 
will give a practicing physician an accurate, 
category diagnosis of any mentally ill patient. 

The necessary information for such an exami- 
nation is already available to the physician by 
the time he completes his history. It becomes 
a matter of organizing the information available 
into a frame of reference which will be useful. 

The psychiatric diagnosis is based upon obser- 
vations made by the physician during his associ- 
ation with the patient. These observations can 
be organized into five areas, namely: anxiety, af- 
fect, thinking, sensorium, and behavior. Observa- 
tions of a sixth area, appearance, may not be 
diagnostic by themselves but lend support to the 
diagnosis. 

Definition of Areas of Mental Status 
1. Anxiety (What Is Its Level? ) 

Anxiety is a feeling state which the patient ex- 
periences. Patients usually refer to this feeling as 
one of being tense, anxious, panicky, restless, 
frightened of some unknown, or may describe it 
in somatic terms. Symptoms such as butterflies in 
the stomach, pressure on the chest, palpitations, 
back pain or lump in the throat, are frequent 
expressions of anxiety. This feeling state when 
expressed through the autonomic nervous sys- 
tem can be observed as a sign by the physician. 
Expressions of anxiety in this manner may take 
the form of increased cardiac rate and pulse pres- 
sure, increased respiratory rate and depth, sigh- 
ing respiration, moist palms, tremor, increased 
muscle tone usually in the back and neck, tight- 
ness of the jaw, excessive blinking, frequency of 
voiding, hyperperistalsis and numerous other 
manifestations. In taking the history the practic- 
ing physician may note changes in the rate of 
speech, the relaxed or tense posture of the patient, 


A practical mental status examination 
useful to the practicing physician is de- 
scribed. 

Dr. Robert E. Froelich is an Assistant 
Professor of Psychiatry, University of Mis- 
souri School of Medicine, and Dr. R. W. 
Froelich is a generalist at the Medical Cen- 
ter, Lebanon. 


as well as the state of alertness. The patient’s 
statements together with the physician’s observa- 
tions will lead to an accurate opinion of the 
level of the anxiety in the patient. 

2. Affect ( Is It Appropriate? ) 

Affect is the feeling tone or pain-pleasure ac- 
companiment of an idea which is experienced by 
the patient. An affect is distinguished from an 
emotion. Emotion is the bodily or physiologic 
expression of the feeling tone or affect, for ex- 
ample, laughing, sighing, flushing or crying. 
Mood refers to a sustained constant affective 
state and must have a considerable duration. The 
affect is sensed in the patient by the observing 
physician. Affect may be described in terms of 
being dull, lacking, flattened, labile, elated or 
ecstatic. In terms of unpleasant affects one uses 
such terms as feeling blue, hopeless, depressed 
or suicidal. The most important aspect of affect 
for diagnostic purposes is whether it is appropri- 
ate to the idea which is being expressed. One 
might refer to inappropriate affect as being 
wierd, unusual, different or silly. A patient speak- 
ing of his father’s death in a jovial way is an 
example of inappropriateness or altered affect . 1 2 3 

3. Thinking ( Is It Logical and Realistic? ) 

Thinking may be disturbed in its form, progres- 
sion or content. In the normal, thought flow is 
realistic, rational and conscious. It appears logi- 
cal to the observer and can be understood and 
followed. 

The progress of thought may be unusually 
slow, lack spontaneity or, in the other extreme, 
may be so rapid that it continues without ever 


355 


356 


MENTAL STATUS— FROELICH 


Missouki Medicine 
May, 1964 


stopping or ending. When continuous speech 
takes place with little or no direction, it is re- 
ferred to as rambling or a flight of ideas. Words 
frequently used to describe abnormal progress 
in thinking have been circumstantial, retarda- 
tion, perseveration, incoherence and blocking. 

The content of thought is judged on its ap- 
propriateness to the situation. Abnormal content 
may be illustrated by preoccupation of certain 
ideas, delusions, hypochondrical thoughts, obses- 
sions, phobias and hallucinations; as illustrated 
by a patient who talks only about her headache 
the day after her husband’s desertion. 

“Reality testing” is a concept closely tied to 
the thinking process. Reality testing refers to 
the patient’s ability to comprehend and act ap- 
propriately to his environment. For example, he 
should recognize that he is in a physician’s of- 
fice or hospital and act appropriately. He should 
accept the physician as a friend and not consider 
him as an enemy who is going to do him bodily 
harm. 

4. Sensorium ( Is the Brain 
Functioning Clearly? ) 

Sensorium includes consciousness, orientation, 
and mental abilities. With respect to conscious- 
ness the patient’s clear mindedness, awareness 
and alertness are considered. Orientation is usu- 
ally considered in three spheres: person, place 
and time. Time may be evaluated in terms of 
day, month, year but also time of day, or time 
until the next meal. Mental abilities refer to the 
patient’s ability to remember recent and past 
events, to read material and handle mathematical 
problems at his usual level, to interpret proverbs 
and to function normally on his job. 

5. Behavior ( Is It Consistent 
With the Patient’s Group? ) 

Behavior is considered in the mental status to 
be overt gross behavior. For example, has the pa- 
tient been arrested frequently, performed un- 
called for or unusual acts, responded differently 
than did others to the same employers, or has his 
behavior been dominated by aggressiveness, 
hostility, passiveness, dependency, alcohol or 
drugs? 

In defining each of these five categories it may 
appear that the mental status examination is an 
overwhelming burden to the practicing physi- 
cian. The details of each group are given in order 
to present the concept as used in psychiatry. It 
is obvious that few psychiatrists, except when 
necessary in a particular patient, would ask a 


proverb or ask the patient to do a mathematical 
problem. These examples are given here to re- 
late the type of information considered under the 
category of sensorium. It is believed that after 
a five or 10 minute history from a patient, phy- 
sicians can give a reliable and satisfactory state- 
ment about each of the five categories. 

Diagnosis 

The rationale for dividing the mental status 
examination and observations into these five 
areas is to relate the observations to the diag- 
nosis. 

For convenience the following four broad 
categories of diagnosis are used. The distinction 
between categories is not always clear but never- 
theless has been found useful. 

1. Psychoneurosis.— The patient who shows 
excessive anxiety with little or no abnormality in 
the other four areas is considered a psychoneu- 
rotic. These patients on occasion have changes 
in affect or mood from that of being depressed 
to being elated; however, this mood is appropri- 
ate to their life situation and is compatible with 
the diagnosis of neurosis. 

2. Psychosis.— A patient whose affect is abnor- 
mal in that it is not appropriate to their life 
situation or thought and also has a disturbance 
of thinking and reality testing is considered psy- 
chotic. A psychotic patient may have some vari- 
ation from the normal in their anxiety level and 
their behavior may be affected by their thinking 
process but these abnormalities are secondary 
to their gross thinking and affective abnormali- 
tis. The variations in anxiety and behavior are 
much less striking than the disturbance in think- 
ing, affect and reality testing. 

3. Organic Brain Syndrome.— The patient who 
has a defect in his sensorium (orientation and 
mental abilities) has an organic brain impair- 
ment. As a result of their organic brain impair- 
ment they may have some changes in appear- 
ance, anxiety, affect, thinking and behavior but 
all of these are much less striking than their loss 
of orientation and ability to think. This is espe- 
cially important when considering a patient in 
the emergency room who has just suffered head 
trauma. If his sensorium is clear and his actions 
abnormal, then appropriate psychiatric care must 
be instituted. If his sensorium is abnormal along 
with abnormal actions then appropriate neuro- 
surgical care must be instituted. 

4. Personality Disorders.— A patient whose be- 
havior is abnormal is considered a personality 
disorder. A patient with a personality disorder 


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MENTAL STATUS— FROELICH 


357 


has essentially normal findings in the areas of 
anxiety, affect, thinking and sensorium. 

Please note table 1 which illustrates the as- 
sociation between the diagnostic category and 
the abnormal area of mental status. 


TABLE 1 

ABNORMAL AREA OF MENTAL STATUS AND 
DIAGNOSTIC CATALOGING 


Abnormal Area 
of 

Mental Status 

Evidence 

of 

Abnormality 

Diagnostic 

Category 

Anxiety 

Level? 

Psychoneurotic 

Disorder 

Affect 

Thinking 

Appropriate? 
Logical and 
realistic? 

Psychotic 

Disorder 

Sensorium 

Oriented and 
clear? 

Organic Brain 
Syndrome 

Behavior 

Normal for group? 

Personality 

Disorder 


Definition of Terms 

The diagnostic terms as used in this article are 
defined in the American Psychiatric Association 
Manual 2 as follow: 

Psychoneurotic Disorders.— The chief charac- 
teristic of these disorders is anxiety which may 
be directly felt and expressed or which may be 
unconsciously and automatically controlled by 
the utilization of various psychologic defense 
mechanism. In contrast to those with psychosis, 
patients with psychoneurotic disorders do not 
exhibit gross distortion or falsification of external 


reality and they do not present gross disorganiza- 
tion of the personality. 

Psychotic Disorders— These disorders are char- 
acterized by a varying degree of personality dis- 
integration and failure to test and evaluate cor- 
rectly external reality in various spheres. In ad- 
dition, individuals with these disorders fail in 
their ability to relate themselves effectively to 
other people or to their own work. 

Organic Brain Syndrome.— This syndrome is 
the result of diffuse impairment of brain tissue 
function, such as is present in alcoholic intoxi- 
cation, delirium, syphilis or trauma. 

Personality Disorders.— These disorders are 
characterized by developmental defects or path- 
ologic trends in the personality structure, with 
minimal subjective anxiety and little or no sense 
of distress. In most instances, the disorder is 
manifested by a life-long pattern of action or be- 
havior, rather than by mental or emotional 
symptoms. 

Summary 

A shorthand practical mental status examina- 
tion which is useful to the practicing physician 
is described. Addendum: “To know what kind of 
a person has a disease is as essential as to know 
what kind of a disease a person has.” 3 

Bibliography 

1. Bleuler, Eugene : Dementia Praecox or the Group of 

Schizophrenias, International University Press, New York, 
page 40, 1950. 

2. Diagnostic and Statistical Manual Mental Disorders, the 
Committee on Nomenclature and Statistics of the American 
Psychiatric Association, American Psychiatric Association Men- 
tal Hospital Service, Washington, D. C., 1952. 

3. Smyth, F. S. : The Place of the Humanities and Social 
Sciences in the Education of Physicians, J. Med. Educ. 3 7 :495, 
1962. 


JAMES N. HADDOCK, M.D.; MR. ORVILLE RICHARDSON, 
and MR. JOSEPH J. SIMEONE, St . Louis 


A New Mental Responsibility Law for Missouri 


MEDICAL ASPECTS 

Any law concerning mental responsibility for 
crime should strive to accommodate two diver- 
gent but not irreconcilable aims: (1) protection 
of the individual from punishment and undue 
deprivation for acts over which he has no sub- 
stantial control because of mental illness, and 
(2) protection of society from the antisocial, de- 
structive behavior of the individual whether he 
is capable of controlling his behavior or not. 


The Mental Responsibility Law which 
became effective on Oct. 13, 1963, is dis- 
cussed from the medical standpoint by 
Dr. Haddock and from the legal phase by 
Mr. Richardson and Mr. Simeone. 

Dr. Haddock is a member of the State 
Mental Health Commission and a mem- 
ber of MSMA Committee on Mental Health. 
Mr. Richardson is an Attorney at Law and 
Mr. Simeone is a Professor in St. Louis Uni- 
versity School of Law. 

This discussion was presented originally 
at a joint meeting of the West Central Mis- 
souri Medical Society and the Vernon Coun- 
ty Bar Association at Nevada, Mo. on June 
13, 1963. 


Heretofore Missouri’s criminal code has been 
both inadequate and inconsistent in fulfilling 
these aims of forensic psychiatry and modern 
jurisprudence. Now Missouri has a new mental 
responsibility law, enacted by the 72nd General 
Assembly, signed into law by the Governor on 
August 19, 1963, and put into effect on October 
13, 1963. Missouri citizens in general and those 
interested in mental health progress in particular 
should be grateful for this effort aimed at liberal- 
izing and humanizing our laws regarding the 
mentally ill. Most of those who have studied this 
new law are hopeful that it will provide a just 
and consistent plan for the protection of the 
mentally ill individual as well as for society at 
large. Actual experience in the courts over a 
period of years will be necessary to determine 


the extent to which it fulfills these expectations. 

As with most states Missouri’s test of mental 
responsibility in criminal cases has been based 
on the M’Naghten rules laid down in England 
in 1843. Briefly stated these rules provide that 
a person is not mentally responsible if he had 
such a defect of reason or disease of mind as not 
to know the nature and quality of the act he was 
doing, or if he did know it, not to know that 
what he was doing was wrong. This test, adopted 
several decades before the founder of the mod- 
ern psychiatric era, Emil Kraepelin, had begun 
to bring order out of chaos in delineating and 
classifying mental illness, has been criticized 
as being too restrictive as well as being anachro- 
nistic in terms of contemporary views regarding 
mental disease. The restrictiveness resulting from 
the use of the word “know” poses a problem for 
the conscientious clinician since so often the in- 
tellectual functioning of the mentally ill person 
may be largely unimpaired. As a consequence 
the statement has been made that literally in- 
terpreted the M’Naghten test would exclude 
only the idiot, the grossly demented senile and 
the severely delirious person from responsibility. 

Numerous attempts at revising and modern- 
izing mental responsibility laws have occurred 
in this country in the last century. In 1870 New 
Hampshire adopted a rule that simply stated that 
an accused is not mentally responsible if at the 
time of the act he did not have “mental capacity 
to entertain a criminal intent. Although this 
test liberalizes the definition of mental respon- 
sibility and embodies the legal concept that it 
is the intent and not the act which establishes 
guilt, it has not gained wide usage. In 1886 the 
“irresistible impulse’ test was first used in Ala- 
bama, but the basic soundness of this concept 
has been seriously questioned. A more recent 
modification has come from the Durham decision 
in the District of Columbia in 1954. It states 
that there is no responsibility if the unlawful act 
is the “product of mental disease or defect. 
Some psychiatrists have hailed this decision as 
a great advance, while some legal experts con- 
sider it too sweeping in its application. Its usage 
has not become wide-spread. In 1958 a Model 
Penal Code with a new definition of mental re- 


358 


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MENTAL RESPONSIBILITY LAW— HADDOCK, ET AL. 


359 


sponsibility was proposed by the American Law 
Institute. This proposal has received serious con- 
sideration in many states and, as will be seen 
later, has formed the basis for Missouri’s new 
test of responsibility. The Currens decision 
handed down in 1961 provides that the person 
is not responsible if, as a result of mental disease 
or defect, he lacked substantial capacity to con- 
form his conduct to the requirements of the law 
which he is alleged to have violated. 

Difficulties of the Medical Witness 

Any test of mental responsibility is only as 
useful as the person or persons interpreting it 
will allow it to be. Thus, a person with strong 
preconceptions of the role free will plays in 
human behavior will tend toward an exacting, 
harsh interpretation of mental responsibility in 
the accused. In contrast, a person more oriented 
toward a deterministic view of human behavior 
with its emphasis on motivation and unconscious 
conflict would be more inclined to hold a large 
number of accused as not mentally responsible. 
In addition to these individual attitudes one 
must reckon with the changing views of society 
toward crime, mental illness and punishment 
from decade to decade and generation to gen- 
eration. Though in general these attitudes are 
more and more toward greater leniency and tol- 
erance, one can discern cyclic fluctuations in 
communities from time to time. 

With this as a background, the role of the med- 
ical witness may be a difficult one. In most in- 
stances the physician, and particularly the psy- 
chiatrist, has been engaged a great deal of the 
time in offering relief from suffering, treating 
disability and fostering rehabilitation in the 
disturbed and disordered. His inclination will 
be to be most concerned with abnormal motiva- 
tion, pathologic processes and potentialities for 
recovery. Aligning his feelings and attitudes in 
this manner, he may find it difficult to hold the 
person entirely responsible. A considerable seg- 
ment of the public may reinforce this tendency, 
and in some instances may influence the physi- 
cian unduly with pleas of a sentimental and un- 
realistic nature. 

At the opposite pole will be found many forces 
influencing the physician toward a more punitive 
and exacting role. A wave of community feeling 
demanding retribution is not uncommon with 
some criminal cases and everyone involved may 
be engulfed by it. In these instances it may be 
easier to side with those forces demanding pun- 
ishment than to do otherwise. Within the indi- 


vidual physician himself anxiety and hostility 
may be aroused to the point that he may feel 
impelled to express his contempt for the accused 
in the form of a medical judgement. 

Caught between these crossfires, particularly 
when accentuated by the adversary method, the 
physician must attempt to adhere to well-estab- 
lished, objective guidelines. His designation as a 
neutral witness may aid this, but will not assure 
freedom from prejudiced demands being made 
upon him. His foremost duty is to determine the 
presence or absence of mental illness. Using the 
same criteria as he would in cases confronting 
him in his daily practice it should be possible to 
present an accurate description of the illness. 
The effects of the illness on the person’s be- 
havior, and particularly on the behavior involved 
in the criminal act, should be determined. When 
these observations are completed one can pro- 
ceed to formulate a reasonable answer to the 
legal question of the individual’s mental respon- 
sibility. 

Important Features of New Law 

Missouri’s new law is an attempt to provide a 
consistent, enlightened method of determining 
the presence or absence of mental responsibility 
in those accused of a crime. If found mentally 
responsible the accused will be tried. If found 
mentally not responsible the accused will be 
committed to a mental hospital for care and 
treatment. In either case society will be pro- 
tected. As a result it is hoped that the plea of 
mentally not responsible (“insanity plea”) will 
no longer be regarded in some instances as a 
ruse for circumventing justice. Instead, it is 
hoped that public confidence in forensic medi- 
cine’s contribution to legal procedures will be 
strengthened. 

In order to provide the appropriate criteria 
for the evaluation of the mental state of the 
accused or convicted person at various stages of 
the criminal process a progressive series of defi- 
nitions geared to fit each step is set forth. Out of 
these definitions and the recommendations that 
follow is developed a consistent plan for han- 
dling the mentally ill person accused or con- 
victed of a crime. It is important for the physi- 
cian to appreciate the significance of each of 
these steps and definitions. 

Early in the criminal process it may be ap- 
parent that the accused is so grossly disordered 
mentally at this time that he cannot even assist 
in the preparation of his defense. To screen out 
these individuals the new law provides that “no 


360 


MENTAL RESPONSIBILITY LAW— HADDOCK, ET AL. 


Missouri Medicine 
May, 1964 


person who as a result of mental disease or de- 
fect lacks capacity to understand the proceedings 
against him or to assist in his own defense shall 
be tried, convicted or sentenced.” 

When the accused comes to trial the most 
important application of the concept of mental 
responsibility occurs. It is here that the new test 
of mental responsibility replacing the M’Nagh- 
ten rules of 1843 is applied. It provides that “a 
person is not responsible for criminal conduct if 
at the time of such conduct as a result of men- 
tal disease or defect he did not know or appre- 
ciate the nature, quality or wrongfulness of his 
conduct, or was incapable of conforming his con- 
duct to the requirements of law.” It should be 
noted that this state of mental irresponsibility 
must be established as having existed at the 
time the alleged crime was committed. Essen- 
tially this new test contains all of the elements 
of the M’Naghten rules, but broadens them 
with the word “appreciate” and the phrase “in- 
capable of conforming.” Though this may not at 
first sight appear to be a substantial change, it 
is nonetheless crucial in that it takes cognizance 
of the changes wrought in the emotional and 
volitional parts of the personality when the per- 
son is mentally ill. The concept of incapability of 
conforming conduct is much broader and yet 
more accurate than the questionable irresistible 
impulse test. 

If the person is declared mentally not respon- 
sible, he is automatically committed to a mental 
hospital for care and treatment. After a period 
of time changes of a spontaneous nature or as a 
result of treatment may occur. Persons acting on 
behalf of the committed person or the hospital 
may institute proceedings for his release. A hear- 
ing will be held in the court from which the 
original commitment was made. The concern at 
this time is the safety of the public as well as 
the welfare of the individual. Therefore the ques- 
tion is whether he still has or in the reasonable 
future is likely to have “a mental disease or de- 
fect rendering him dangerous to the safety of 
himself or others or unable to conform his con- 
duct to the requirements of the law.” 

Among those persons convicted of crime, signs 
of mental disease may become manifest after he 
starts serving his sentence even though no evi- 
dence of this may have been present prior to 
conviction. Therefore provision is made for the 
inmate who is found to be mentally ill to be 
transferred to a mental hospital for care and 
treatment. When and if he recovers he will be 
returned to prison to complete his sentence, or 


if his sentence has expired while hospitalized 
his discharge will be considered. 

Those persons condemned to death may de- 
velop mental illness during the interval between 
conviction and execution. If “as a result of men- 
tal disease or defect he lacks the capacity to 
understand the nature and purpose of the pun- 
ishment about to be imposed upon him or to 
recollect matters in extenuation, arguments for 
executive clemency, or reasons why the sentence 
should not be carried out” he shall not be exe- 
cuted and care and treatment in a mental hos- 
pital ordered. If recovery occurs he will be re- 
turned to prison and the execution carried out. 

Diagnostic Considerations 

Attempting to relate what is essentially a legal 
definition to a diagnostic classification which has 
been derived from clinical experience presents 
obvious difficulties. Yet the fact that Missouri’s 
new definition of mental responsibility clearly 
demands a definite diagnosis would make such 
an attempt important. Just as one cannot treat 
patients on the basis of rules of thumb, neither 
can one stamp accused persons as mentally re- 
sponsible or not responsible according to diag- 
nostic label only. In the past the tendency to 
equate the legal term “insanity with the medi- 
cal term “psychosis” has led to the unfortunate 
and inaccurate practice of considering all per- 
sons with psychoses to be mentally not respon- 
sible. Actually many persons with psychoses can 
be considered mentally responsible. With these 
points in mind one can approach the matter of 
diagnosis and its relationship to mental respon- 
sibility. 

The psychoneurotic disorders would almost 
never be considered the basis for a declaration 
of mental irresponsibility. In some instances the 
presence of a neurotic disorder may be estab- 
lished for the purpose of mitigating the punish- 
ment, but this is a matter different from exclu- 
sion from mental responsibility. 

The conditions usually termed psychopathic, 
sociopathic or character disorders present more 
of a problem. They are especially important 
since their very nature leads to frequent infrac- 
tions of the law. Missouri’s new law specifically 
states that those individuals whose only evidence 
of mental disease or defect is the presence of 
“repeated criminal or otherwise antisocial con- 
duct” would not be considered to have a mental 
disease or defect and therefore would be held 
mentally responsible. Th's in itself would result 
in many psychopathic p?rsonalities being held 


Volume 61 
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361 


responsible. But the use of the qualifying word 
“only” in this definition allows many psycho- 
pathic personalities who have manifestations oth- 
er than repeated criminal conduct to be con- 
sidered for exclusion from responsibility. Yet 
even in those cases many would be held respon- 
sible. It is possible that in some instances the 
severely disordered psychopathic personality 
would be considered mentally not responsible. 
Those psyc